blog.weatherbee.nethttp://weatherbeenetwork.net/Tue, 23 Feb 2016 18:11:09 +0000en-USSite-Server v6.0.0-13633-13633 (http://www.squarespace.com)Our Blog Has MovedHeather Wilson, PhDTue, 23 Feb 2016 18:11:09 +0000http://weatherbeenetwork.net/blog/2016/2/23/our-blog-has-moved50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:56cc9d1bd210b855b9b1b667Thank you for visiting the Weatherbee Blog! We have relaunched our blog on the new Hospice Compliance Network website. All our blog posts have been posted to the new site.

Please visit the blog page and if you haven't already signed up to receive notifications of new blog posts, please do so there.

]]>What do your IDG meetings reveal about quality of care?Joy BarryFri, 11 Dec 2015 16:57:55 +0000http://weatherbeenetwork.net/blog/2015/12/11/idg-mtgs50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:566af40325981da0b617cd98Recently, one of Weatherbee’s senior consultants observed a hospice’s
interdisciplinary group (IDG) meeting as part of an on-site mock survey of
the organization. The 4-hour meeting included a review of all deaths and
admissions that occurred during the prior 2 weeks, as well as a review of
all existing patients on the hospice’s census. A total of 30 patients were
discussed. The medical director, 4 registered nurses (RNs), 2 social
workers, a chaplain, and the volunteer coordinator were present during the
meeting.

Recently, one of Weatherbee’s senior consultants observed a hospice’s interdisciplinary group (IDG) meeting as part of an on-site mock survey of the organization. The 4-hour meeting included a review of all deaths and admissions that occurred during the prior 2 weeks, as well as a review of all existing patients on the hospice’s census. A total of 30 patients were discussed. The medical director, 4 registered nurses (RNs), 2 social workers, a chaplain, and the volunteer coordinator were present during the meeting.

At first blush, the consultant was impressed with the overall organization and flow of the meeting. The meeting followed a typical structure, with each nurse presenting a clinical summary of the patient’s status and current plan of care. Each patient’s electronic health record (EHR) was projected on a large screen during the meeting, and the team reviewed the documentation to assure accuracy and completeness.

As she listened, the consultant wondered how other potential observers would experience the meeting. For example: If she were a CMS or state surveyor, would she be impressed with the hospice, the team, and/or the meeting or would she cite deficiencies? If she were one of the patients or family members being discussed, would she be grateful she was under this particular hospice’s care or would their dialogue be upsetting? She listened more critically, and noted the following:

While the nurses took turns reading aloud the summaries they had entered into the EHR in advance of the IDG meeting, the rest of the team paid no attention at all – they were typing on their laptops, shuffling papers and passing them around the room, signing bereavement cards, having side conversations with one another, eating breakfast, leaving the room to fetch coffee, etc.

The RNs reported, many times, not having met their assigned patients yet even when the patients had been admitted 2 weeks prior. The consultant found herself wondering: Who completed the initial and comprehensive assessments? Who was monitoring the patient’s clinical/functional status and medication supply? How long did these nurses expect their patients to live; why was there no sense of urgency to assess and address patient/family needs?

A number of patients reportedly “declined all non-nursing disciplines." The consultant wondered: Why is this so? Was a particular case manager not explaining the interdisciplinary nature of hospice care to her patients/families? How could holistic end-of-life care be provided by a single discipline?

The medical director never uttered a single word; he merely signed the forms that were placed in front of him looking bored and disinterested. He left the room twice for extended periods, returning with a weary harrumph as he sat down. However, the meeting went on during his absences nonetheless. The consultant wondered: If his presence were not a regulatory requirement, would he even bother coming to these meetings?Why is he so disengaged? Why is he a hospice medical director?

The team was complying with requirements of 418.56(d) to: review, revise and document the individualized plan as frequently as the patient’s condition requires, but no less frequently than every 15 calendar days. But is the “letter of the law” all that matters? Is “paper compliance” good enough? As the patient-specific reports continued, the consultant became increasingly appalled by some of the information and commentary she heard. For example:

A patient on service for 5 days died without seeing a nurse after his initial admission assessment. The consultant wondered: Didn't he need additional nursing visits? Did he die alone? How, and how well, were his symptoms palliated? Did his family understand what was happening; were they prepared for his rapid decline and death?

Contrast the above with another patient who was on service for over 2 years. Her family reportedly “wasn’t prepared for her death at all.” The consultant asked herself: Why was the family unprepared after 2 years of hospice care? Was the family in denial with regard to the patient’s mortality; ignorant of her disease trajectory; possibly uninvolved or uncaring until it was too late? How does this happen when the team had so much time prior to the patient’s death to prepare the family with education and interdisciplinary support? Or, was this one of the patients who had “declined all non-nursing disciplines”? Even so, that wouldn’t explain the lack of preparation.

A relatively young patient with terminal bone cancer and contracted extremities reportedly needed a costly electric wheelchair for his mobility, positioning, comfort, and safety. The social worker suggested discharging the patient, letting him procure the device from Medicare, and then readmitting him so the hospice wouldn’t have to pay the cost. The consultant, cringing as the “F-word” came to mind (i.e., fraud), prayed that the social worker wasn’t serious and the team wouldn’t follow through with her suggestion.

A patient with end-stage Alzheimer’s disease reportedly “talks and talks all the time in her native German, but no one can understand a word she says…no one in the facility speaks German, and she has no family or friends…she always seems so happy to have company and just lights up whenever we arrive to visit her.” The consultant mused: How do you know this patient is appropriate for hospice care with a primary diagnosis of Alzheimer’s disease if no one can understand what she’s saying? How did you evaluate her as having a FAST score of 7b? She could be alert and oriented for all anyone knows (or in pain, or hungry, or in need of the bathroom, or frightened, or lonely, etc.).

A few patients reportedly had pain or other symptoms that required palliation, but the hospice nurses were “having difficulty” obtaining orders from the attending physicians and/or the facilities where the patients resided. The consultant wondered: Why was no one jumping out of their seat to object to these unnecessary – not to mention unfortunate and inexcusable – treatment delays? Was substandard care and mediocrity the acceptable norm at this hospice?

Next, a primary caregiver was described as being “totally selfish [because] he wants his wife to be awake and alert at any cost…he doesn’t want her doped up and drowsy.” The patient “is in extreme pain and needs palliation.” Although the RN obtained new pain management orders from the patient’s attending physician the prior week, she was not planning to implement the orders until “additional caregiver teaching occurs.” The consultant thought: Am I the only person in the room who finds this outrageous? If the patient has “extreme pain” and is in need of palliation, why weren’t the new orders implemented immediately with concomitant caregiver teaching?

Another patient’s family was described as being “totally and completely overwhelmed.” The social worker indicated, “the Chaplain’s visit frequency should be ‘TBD’ [to be determined]…but she [the patient] doesn’t really want spiritual care.” The Chaplain indicated she would call the patient to schedule a visit, and the social worker quickly quipped, “let her call you…you’ll soon learn in this job not to work any harder for your patients and families than they’re willing to work for themselves!” The consultant almost cried out: Why won’t you proactively provide support to patients/families when it is so clearly needed and warranted? Do you not understand your responsibilities and obligations as healthcare professionals? Can you not appreciate the fact that these patients have a limited life expectancy and, as such, time is of the essence?

Another patient was described as “having terrible hallucinations.” The RN said the caregiver didn’t want to medicate the patient [his wife] as, “they [the hallucinations] are her only friends…they’re a great source of socialization for her…she likes it when her friends come to visit.” The RN went on to say that some of the hallucinations were quite negative and disturbing to the patient. Although the nurse said she wasn’t in agreement with withholding the medication, she “would honor the caregiver’s choices.” The consultant wondered: Why hadn’t the RN attempted to address the patient’s hallucinations proactively with concomitant caregiver support and education? Could the patient be experiencing physical pain and/or emotional/spiritual distress? Would she benefit from the involvement of other disciplines? Do the RNs function as gatekeepers for, or barriers to, other discipline involvement? Do RNs always defer to caregiver wishes despite potential patient suffering?

Lastly, a patient reportedly “benefitted tremendously” from a recent inpatient stay for pain management at the hospice’s inpatient unit. The RN said she felt badly she “hadn’t suggested the inpatient stay months ago.” She went on to say that “it really should have happened months and months ago…he would have had much better quality of life…if only I’d known how much better he’d be feeling.” The consultant, almost despairing at this point, thought to herself: If it should have happened “months and months ago,” why didn’t it? Where’s the team involvement? Where’s the physician oversight? Why are these patients experiencing such treatment delays? How is this a high quality end-of-life experience? How is this "value-added" hospice care worthy of being billed to, and paid for by Medicare?

I hesitated writing this blog post and sharing this consultant's experience. Our goal at Weatherbee is certainly not "hospice-shaming" or adding to negativity surrounding the quality of care provided by hospices. But, unfortunately, the examples from this one IDG meeting are not atypical. As an industry, we have to figure out how to do better, how to improve the quality of care provided by hospices so patients and their families receive the very best care available at the end of life. I can only hope readers of this blog post agree that the quality of this hospice’s care is, at best, highly suspect; at worst, substandard, dangerous, and completely unacceptable.

So, what’s the take-away here?

If you don’t already do so, observe an IDG meeting at your hospice. Listen -- with “fresh ears” -- to what your team members say, to how each discipline reports, and to how they speak about the patients and families under their care. Here are some questions to ponder as you observe your IDG meeting:

Is the care that’s being offered and delivered truly interdisciplinary?

Are all core members present and accounted for, and participating in a meaningful way?

Are plans of care appropriate, and are they reviewed and updated at least every 15 days (or more frequently if the patient’s condition warrants)?

Are visit frequencies appropriate and honored and based on patient need as opposed to staff convenience?

Who’s leading the team, and is it the person who’s responsible to do so (versus a self-appointed and perhaps inadequately trained team member)?

Are relatedness determinations, payment-related obligations, and other decisions appropriate, justifiable, and supported by clinical record documentation?

Would you be proud to invite patients/families (or surveyors) to your IDG meetings?

Would you be willing to refer one of your loved ones to your hospice?

Would a surveyor praise you for having a meaningful IDG meeting, good patient/family outcomes, and excellent quality of care; or, would your hospice be in immediate jeopardy for negative outcomes that resulted in (or could have resulted in) harm to one or more patients?

I suppose it’s possible for a hospice to have a less-than-ideal team meeting and still deliver good care. However, given the patient descriptions cited above, it’s doubtful this is one of those hospices. Don’t let your hospice or the interdisciplinary team operate unchecked. The last thing you want – or your patients/families need – is a negative outcome that could have been prevented.

Thank you for reading this blog post. I look forward to your comments.

Posted by Joy Barry, RN, MEd President and Co-Owner of Weatherbee Resources, Inc.

]]>CMS Issues New Guidance Related to Redetermination and Reconsideration Claim RequestsCarrie CooleyFri, 18 Sep 2015 17:36:16 +0000http://weatherbeenetwork.net/blog/2015/9/18/redeterminations50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:55fc42f9e4b051db9c8fdd6fIn the midst of tremendous challenges facing the hospice industry, the
Centers for Medicare and Medicaid Services (CMS) has issued guidance to
Medicare Administrative Contractors (MACs) and Qualified Independent
Contractors (QICs) that is likely to have a positive effect on hospice
providers. The guidance from CMS directs MAC and QIC reviewers to limit
the redetermination and reconsideration review to the reason(s) the claim
was initially denied for all post-payment reviews.

In the midst of tremendous challenges facing the hospice industry, the Centers for Medicare and Medicaid Services (CMS) has issued guidance to Medicare Administrative Contractors (MACs) and Qualified Independent Contractors (QICs) that is likely to have a positive effect on hospice providers. The guidance from CMS directs MAC and QIC reviewers to limit the redetermination and reconsideration review to the reason(s) the claim was initially denied for all post-payment reviews.

The updated guidance from CMS applies to all post-payment redetermination or reconsideration appeal requests received by the MAC or QIC on or after August 1, 2015; however, the guidance will not be applied retrospectively. This recent CMS guidance will also not apply to claims being reviewed on a pre-payment basis by the MAC or QIC.

Background

In the past, MACs and QICs had a great deal of discretion when conducting clinical record reviews for redetermination and reconsideration appeal. During past post-payment appeal reviews, the MAC or QIC reviewer could review all aspects of coverage and payment and develop new issues (i.e., reason(s) for claim payment denial) regardless of whether a prior MAC reviewer identified the issue or if the hospice provider “cured” the reason for the prior claim denial.

Example (Historical MAC/QIC Review):

Sample Hospice submitted clinical records for an Additional Development Request (ADR) for a patient’s May 2015 dates of service. Unfortunately, Sample Hospice failed to include the Face-to-Face Encounter (F2FE) visit documentation associated with the benefit period from 04/10/15 through 06/08/15; therefore, the MAC issued a technical claim payment denial.

The MAC redetermination reviewer reviewed all aspects of coverage and payment and acknowledged the presence of the F2FE visit note. However, the reviewer determined that the clinical record documentation did not support the patient’s terminal prognosis; therefore, the MAC issued a payment denial of the redetermination appeal.

Example (with new CMS guidance applied):

Sample Hospice submitted clinical records for an ADR for a patient’s May 2015 dates of service. Unfortunately, Sample Hospice failed to include the F2FE visit documentation associated with the benefit period from 04/10/15 through 06/08/15; therefore, the MAC issued a technical claim payment denial.

The MAC redetermination reviewer acknowledged the presence of the F2FE (the reason for the previous denial) in the clinical record documentation and issues a favorable decision for payment.

What You Need to Do

Although the recent CMS guidance will likely benefit hospice providers during redetermination and reconsideration appeals, a timely and organized response to the initial ADR request is still essential in seeking a positive payment determination from the MAC. The following are some suggestions for ADR response:

Ensure you submit all requested ADR documentation to the MAC on time. Failure to do so will result in an automatic claim denial;

When sending clinical record documentation to the MAC, request delivery receipt confirmation (to serve as documentary evidence of a timely submission);

Consider including a summary cover letter (created internally or by an independent expert reviewer like Weatherbee Resources) with each clinical record;

Organize the clinical record to the greatest extent possible. Consider including a table of contents that directs the reviewer to all pertinent technical and clinical record documentation elements; and

Have an internal validation process (prior to submitting the clinical record to the MAC) to ensure the inclusion of all requested elements.

Conclusion

As stated previously, CMS’ guidance regarding post-payment redetermination and reconsideration appeals is a move in the right direction that will likely benefit the hospice industry; however, the goal of all hospice organizations should be to obtain a positive claim determination at the ADR level and not be dependent on a good outcome at the redetermination and/or reconsideration appeal levels based on the new guidance from CMS. In order to do this, the hospice must ensure that (1) all technical elements (e.g., certification/recertification of terminal illness, Physician Narrative, Face-to-Face encounter, etc.) are valid and (2) clinical record documentation supports the patient’s terminal prognosis throughout the dates of service under review.

If anyone has any recommended practices related to ADRs or appeals, feel free to share them in the “Comments” section so that all may benefit.

]]>Returning Medicare and Medicaid Overpayments - Better Act Fast!Heather Wilson, PhDMon, 24 Aug 2015 20:47:28 +0000http://weatherbeenetwork.net/blog/2015/8/24/returning-medicare-and-medicaid-overpayments-better-act-fast50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:55db7cd0e4b09e4a0cc8c1efDon’t shoot the messenger but compliance with Medicare and Medicaid rules
just got tougher for hospice organizations. In the first judicial opinion
on when a Medicare or Medicaid “Overpayment” is “identified” for purposes
of the Affordable Care Act’s (ACA) 60-Day Repayment Law, a New York federal
court’s interpretation complicates the already difficult task providers
face in having sufficient time to assess and quantify potential
overpayments.

Don’t shoot the messenger but compliance with Medicare and Medicaid rules just got tougher for hospice organizations. In the first judicial opinion on when a Medicare or Medicaid “Overpayment” is “identified” for purposes of the Affordable Care Act’s (ACA) 60-Day Repayment Law, a New York federal court’s interpretation complicates the already difficult task providers face in having sufficient time to assess and quantify potential overpayments. An August 3, 2015 decision in United States v. Continuum Health Partners Inc. marks the first time a court has interpreted the provision of the ACA that requires providers to return Medicare and Medicaid overpayments to government agencies within 60 days of the overpayment being “identified” (“60-Day Rule”). Rejecting the argument by defendants Continuum Health Partners and three member hospitals that a claim is “identified” when specific overpayments are conclusively pinpointed, the court wrote that such an interpretation would create “a perverse incentive to delay learning the amount due” and instead found that the 60-day clock begins running when the provider is on notice of potential overpayments—even where the exact claims or amounts are not yet known.

As part of the “Medicare and Medicaid program integrity provisions,” the ACA requires that any person who receives an overpayment shall report and return the payment to the appropriate agency or carrier and notify the agency or carrier in writing about the reason for the overpayment. The recipient of the overpayment must do so by the later of (1) “60 days after the date on which the overpayment was identified” or (2) the due date of “any corresponding cost report, if applicable.” Since its implementation, the 60-Day Rule left open many questions as to how to determine when the “clock” begins to “tick”. The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule on the topic in February 2012 stating that a provider has “identified” an overpayment for purposes of the 60-day clock when it has “actual knowledge of the existence of the overpayment or acts in reckless disregard or deliberate ignorance of the overpayment.” A final rule for Medicare Part A providers, including hospices, still has not been issued, and questions continue to abound. The Continuum decision marks the first judicial interpretation of the 60-Day Rule provisions.

The government’s False Claims Act complaint, initiated by a whistleblower who had been terminated by the health system, essentially alleged that the defendants, as a result of a computer error, double billed for certain services rendered to Medicaid beneficiaries, resulting in the defendants receiving payments from both a managed care plan and Medicaid. The whistleblower had sent a detailed list of potential overpayments (about half of the claims on the list had resulted in an overpayment), but despite the government’s contention that it had at that point “identified” the overpayment, the hospitals over a two year period failed to refund the bulk of the “identified” overpayments. Defendants argued that the government’s interpretation that an overpayment is identified when it is put on reasonable notice of potential overpayments, even if not yet quantified, would “impose an unworkable burden” on providers to report and return potential overpayments within 60 days. This argument was not persuasive to the judge, who commented that “[i]t would be an absurd result to construe this robust anti-fraud scheme as permitting willful ignorance to delay the formation of an obligation to repay the government money that is due.”

However, the court noted that the 60-day window for returning an overpayment is an “obligation” under the ACA that does not, unto itself, establish liability under the False Claims Act (FCA). “Rather, in the reverse false claims context, it is only when an obligation is knowingly concealed or knowingly and improperly avoided or decreased that a provider has violated the FCA.” Thus, the court concluded, “well-intentioned” providers “working with reasonable haste” to address the overpayments identified should be safeguarded by prosecutorial discretion because “[s]uch actions would be inconsistent with the spirit of the law and would be unlikely to succeed.”

Main Takeaways

Although this district court decision is binding only in one judicial district, it carries great weight given that it is the first and only judicial interpretation of a vague term in the ACA (what it means to “identify” an overpayment for purposes of the 60 Day Rule). Even in the absence of a final regulation by CMS on the 60 Day Rule, Medicare, state Medicaid agencies, the Department of Justice, the OIG and whistleblower attorneys are all likely to argue (now with some support) that the 60 day clock begins to tick when a provider is put on reasonable notice of an overpayment and has only 60 days from that time to report and refund the overpayments. Failure to do so may put the organization at some risk of a “reverse” false claim under the False Claims Act, with its attendant punitive penalties, especially if the hospice does not act with reasonable diligence to determine the amount of the overpayment. Practically speaking, this means hospices must devote substantial compliance and billing resources when it has reasonable notice of a potential Medicare or Medicaid overpayment to tackle the issue within 60 days. There is no legal exception for “thinly staffed compliance programs” and hospices should create workable strategies to address potential refunds.

Posted by Howard Young, Esq. - Morgan Lewis hyoung@morganlewis.com Howard Young is also a regular faculty member at Weatherbee's Hospice Regulatory Boot Camp.

]]>The 2016 Hospice Wage Index Proposed Rule - Some ThoughtsHeather Wilson, PhDThu, 25 Jun 2015 17:03:22 +0000http://weatherbeenetwork.net/blog/2015/6/25/2016wageindex50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:55811f8ce4b073fcfef78ba2I have been thinking a lot about the FY 2016 Hospice Wage Index proposed
rule (NPRM). The more I have thought about it, however, the more complex
it seems. I have needed to harken back to my salami methodology (described
here) and try to break it down into manageable chunks. The only chunks I am
focusing on are the ones having to do with payment reform (tiered
reimbursement and the Service Intensity Add-On) and the "clarification" to
include all diagnoses on claim forms (and the related - excuse the pun -
virtually all / related and not related / prognosis vs diagnosis
conundrums).

Introduction

I have been thinking a lot about the FY 2016 Hospice Wage Index proposed rule (NPRM). The more I have thought about it, however, the more complex it seems. I have needed to harken back to my salami methodology (described here) and try to break it down into manageable chunks. The only chunks I am focusing on are the ones having to do with payment reform (tiered reimbursement and the Service Intensity Add-On) and the "clarification" to include all diagnoses on claim forms (and the related - excuse the pun - virtually all / related and not related / prognosis vs diagnosis conundrums).

Another, perhaps more apt metaphor comes to mind with these salami chunks - seeing the forest through the trees. In this case, the forest is the Medicare Hospice Benefit and the trees are all the details in the NPRM - the first 60 days more money / after 60 days less money, the count of days, the Service Intensity Add-On (SIA) with only skilled visits, no SNF patients, all diagnoses on the claim forms including those related to mental health, etc., etc. Yes, with all these "trees" we can categorize, organize, recite the new requirements, enumerate the potential or real problems with each in order to assemble a comment letter to CMS by June 29th. But in so doing, it is easy to lose sight of the forest, the bigger picture - the Medicare Hospice Benefit.

The Medicare Hospice Benefit (MHB)

In the NPRM, as in all other rules written by CMS, there is a lengthy preamble discussion of the history of the MHB. In addition, throughout the NPRM, CMS references the MHB as established in statute, with implementing regulations finalized in December 1983.

And therein lies the problem - 1983 - 32 years ago. The MHB was developed in a world very different from the one we live in today and the one in which hospices provide end of life care. Think about it. Where were you and what were you doing in 1983? For the youngsters among us - were you even born or out of toddlerhood in 1983? There were no VCRs much less DVRs, laptops, tablets, cell phones, electronic health records, social media, email, streaming video, online education - it was such a different world back then. And it was a different world for hospices - the majority of hospice patients had a cancer diagnosis, their terminal illness followed a common trajectory, establishing a 6 month prognosis was more straightforward and the related / not related issue was not a big deal.

The MHB was wonderful back in 1983 and a testament to its "wonderfulness" is how long it has lasted. But it needs to change and the first "incremental steps" toward payment reform of the tiered reimbursement with the SIA does not cut it. It is akin to putting a band-aid on something that requires major statutory surgery. This does not mean that the payment reform proposed in the NPRM is not good or should not happen, but it is not going to solve the problems CMS is hoping it will (i.e. long lengths of stay, frequency of skilled visits, hospice care in nursing homes, etc., etc.) It may help with the current misalignment of payment with hospice service intensity and give the long talked about U-shaped curve a fair trial - I suppose that remains to be seen. But it does not address some of the fundamental problems with the MHB that are threatening the existence of many hospices, especially the smaller ones.

I have described elsewhere some of the issues with the MHB. This NPRM, when looking through the trees, further increases the urgency I feel to look at the forest and the need to advocate for fundamental change in the MHB. Let me try to explain by discussing some of the trees.

Payment Reform

The NPRM proposes the first substantive payment reform since the inception of the MHB with a tiered reimbursement system for routine home care and a SIA. While I do not want to minimize or diminish the extensive effort, research, and resources that have gone into CMS' efforts at payment reform, I am concerned that many of their findings seem based on outlier hospices (of the "proceed until apprehended" variety) and their solutions are not focused on these outliers but addressed to the whole industry. CMS has the data necessary to identify aberrant providers - why don't they scrutinize the hell out of them, penalize them and put them out of business?

I also have concerns about the data upon which CMS is basing its proposals. Are the appalling statistics related to the lack of visits at the end of life only based on skilled RN and SW visits? If so, is it possible the stated low frequency of visits is misleading because it is not taking into account perhaps a whole vigil team of volunteers at the patient's bedside or perhaps a chaplain was there with the patient and family offering comfort and support, or an LPN or hospice aide who are often the most present and important members of the team? Maybe there were NO visits and that truly is appalling. But CMS can't have it both ways - affirming and emphasizing the interdisciplinary nature of hospice but only giving credence to visits by RNs and social workers.

Also, somewhat related to this, the SIA was designed in a manner taking into account "operational concerns and programmatic complexity led us to explore the concept of a SIA that could be implemented with minimal systems changes that limit reprocessing of hospice claims due to sequential billing requirements." p. 25857

Shouldn't something as important as the first substantive step toward hospice payment reform be designed to be the best it can be with concomitant system changes as needed? And while the operational concerns and programmatic complexity of CMS were taken into consideration, what about that for hospices? Certainly the first significant change to hospice reimbursement in 32 years would seem to warrant a demonstration project or, at the very least, a trial run to assure CMS' systems can in fact manage the changes, assist hospices with figuring out managing their account receivables, billing, and avert potential unintended negative consequences.

"Clarification" of all diagnoses on claims

Now on to my favorite trees - the "virtually all," related/not related, and prognosis vs diagnosis, which I believe are all more or less under the rubric of the clarification of all diagnoses on claims in the NPRM.

For fun, let's parse each one of these trees separately within the NPRM and hope that by the end of it, we have a better view of the forest - the unwieldy MHB.

"Virtually all"

Here is the non-statutory, non-regulatory language that first appeared in the preambles to the proposed and final original implementing regulations of the MHB in 1983 (let me repeat, 32 years ago):

"It is our general view that hospices are required to provide virtually all the care that is needed by terminally ill patients. ...Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis; all conditions are considered to be related to the terminal illness."

In the NPRM, this "tree" is referred to a number of times. Let's look at two of the most interesting:

"We continue to expect hospices to adhere to the long-standing policy to provide ‘‘virtually all’’ care during a hospice election as articulated in the 1983 Hospice Care proposed and final rules as well as most recently in FY 2015 Hospice Wage Index and Payment Rate Update final rule." p. 25847

What is interesting here is that I think suddenly, the "virtually all" language has been promoted to "long-standing policy." I am not a lawyer but I somehow suspect that preamble language does not quite rise to the level of policy.

Then there is this:

"As stated in the 1983 hospice final rule, and reiterated throughout hospice rules since implementation of the benefit, it is our general view that the waiver required by the law is a broad one and that hospices are required to provide virtually all the care that is needed by terminally ill patients (48 FR 56010). p.25877

It is just not true that this "virtually all" language has been reiterated for 32 years. Obviously I am not anal enough (maybe that is not obvious) to look through all hospice rules "since the implementation of the benefit" but I did look at a few prior to 2013 and could not find this language. Given that the final rule of the "new CoPs" published in 2008 is arguably the most significant rule published since the implementation of the benefit, I did look at that and did not find any "virtually all" all language. I find it curious that CMS has been trying to pass this "virtually all" language off as "longstanding policy" that has been reiterated forever when in fact it only reappeared (with a vengeance) in relationship to Part D a few years ago.

Related/Not Related

When CMS is promoting the "virtually all" concept, as it has been for the past few years, the issue of what is or is not related to the terminal diagnosis (and prognosis - more on that next) is critical. Here is the crux of the issue with related/not related:

... Therefore, unless there is clear evidence that a condition is unrelated to the terminal prognosis; all conditions are considered to be related to the terminal illness. It is also the responsibility of the hospice physician to document why a patient’s medical needs will be unrelated to the terminal prognosis. p. 25836

NHPCO and others have tried valiantly to maintain the critical role of the physician in determining on a case-by-case basis what is related or not related to the terminal diagnosis/prognosis. But here is the kicker from page 25878 of the NPRM within the context of CMS' concern regarding hospices unbundling services:

We have received anecdotal reports from non-hospice providers who have rendered care and services to hospice beneficiaries in which the non-hospice provider states that the care given was related to the terminal prognosis of the individual. These reports go on to say that they have contacted hospices to coordinate the care of the hospice beneficiary only to be told by those hospices that they disagreed with the non-hospice providers’ clinical judgment that the care was related to the terminal prognosis. ... These non-hospice providers stated that they disagreed with this practice, and considered it fraudulent. As such, they were unable to be reimbursed by the hospice or by Medicare for services provided that they felt were the responsibility of hospice. p. 25878

No reference to the hospice physician's clinical judgment here. What is critical in this is CMS' seeming willingness to take the "non-hospice provider's clinical judgment" regarding relatedness over the hospice's. This is only one of many potential examples of the slippery slope of related/not related. It becomes even more of a quagmire when trying to determine relatedness to diagnosis, prognosis or both.

Diagnosis vs Prognosis

I wrote a whole blog post on this issue here and the topic just seems to get murkier. Within the context of the NPRM it remains confusing. One might well ask if it is a semantics issue. The dictionary defines prognosis as:

1.Medicine/Medical. a forecasting of the probable course and outcome of a disease, especially of the chances of recovery. 2. a forecast or prognostication.

In hospice, eligibility has been determined by whether the prognosis for, or outcome of, a patient's terminal illness is death within 6 months if the illness runs its normal course. What has become confusing (and critical) lately is CMS' definition of prognosis, which is reiterated in the NPRM that hospices must consider what factors influence that terminal prognosis, or, as CMS states:

....what factors influence the terminal prognosis of the individual (that is, what conditions render the individual terminally ill and which conditions are related). p. 25880

Let's look at a ridiculous (maybe) example. For the rest of my life I am going to have a diagnosis of S/P TKR (status post Total Knee Replacement). Let's imagine that someday in the very distant future I am on hospice with a primary diagnosis of bone cancer. That is the condition rendering me terminally ill. While I am on hospice the cancer affects the knee joint to such a degree that I am writhing in pain and need revision surgery to replace or resettle the knee prosthesis in order to palliate my pain and enhance the quality of my life for my remaining days. Since the knee problem was potentially a result of the bone cancer and would contribute to a shortened prognosis if not addressed, would something that occurred long ago in the past (the TKR) now be considered related and the hospice be responsible for paying for the knee surgery and inpatient stay? Let's complicate it more - change my terminal diagnosis to cardiac disease but my knee wore out because the prosthesis was old and in need of replacement. I was in massive pain - would the hospice be on the hook then because my pain would be influencing my prognosis and need management?

We can pick that example apart but the point is that the all-inclusive prognosis with virtually all care of hospice patients being related to the terminal prognosis and therefore the financial responsibility of the hospice is unreasonable and unsustainable. This is particularly true for small hospices and, quite frankly, it is also the reason "unbundling" occurs.

Clearly, I could go on and on and I have. Let's try to wrap this up with the clarification of all diagnoses on claim forms.

Clarification of all diagnoses on claim forms

A requirement of the NPRM is that hospices must now list all of a patient's diagnoses on hospice claim forms. CMS states that they are clarifying existing policy but I think there has been a lot of confusion regarding this issue. If, as CMS states, over 77 percent of hospice claims reported only one diagnosis in 2010, and this is supposedly a bad thing, there is obviously a disconnect. I refuse to believe that 77% of hospices would wantonly disregard a CMS directive and only self- correct to 49% in 2014. CMS stated that in the 2013 Hospice Wage Index they said hospices should report all related (not unrelated or coexisting) diagnoses on claim forms even though coding guidelines required the reporting of all diagnoses that affect patient assessment and planning (p. 25880). Hence the confusion. It is even confusing figuring out how confusing it is!

So the clarification is now to report all diagnoses, related and not related. CMS states that the purpose of this is to assure hospices are doing adequate comprehensive assessments and to determine costs. My bet is that the data will eventually be used to determine if hospices have adequately assumed financial responsibility for EVERYTHING wrong with the patient. I would imagine a lot of "non-hospice" scrutinizers are going to lend their opinions on the relatedness issues.

There is also a new an emphasis in the NPRM that hospices assess and report if a patient has a mental illness, in addition to his or her principal terminal diagnosis. Is the assumption here that hospices have or should acquire expertise in managing mental illnesses and assume financial responsibility for psychiatric medications or inpatient psychiatric hospitalizations and/or clearly document how the mental illness does or does not contribute to or influence the terminal prognosis?

Do you see how things are getting / have gotten out of hand?

Conclusion

So enough. I believe that the "trees" discussed above are the proverbial straws that are breaking the MHB's back. At the risk of being totally annoying with my forest/trees metaphor - let me conclude by saying that we can and should send comment letters to CMS in an attempt to put out some of the fires in some of the trees in the NPRM, but please, please, with that, let us also try to figure out how to salvage the forest because it is burning.

Posted by Heather P. Wilson, PhD, CHC CEO, Weatherbee Resources, Inc.

]]>The Physician Narrative Attestation: Beware of the Not-So-Fine PrintSuzanne Karefa-Johnson, MDThu, 21 May 2015 15:51:59 +0000http://weatherbeenetwork.net/blog/2015/5/21/the-physician-narrative50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:555df52be4b09b430c1cad43Last year, a hospice medical director in Pennsylvania, was convicted of
Medicare fraud for false certifications of the clinical eligibility of
patients for hospice care. The wrongdoing involved appears to be fairly
black and white. However, another more nuanced area of regulatory
oversight of physicians is looming on the horizon.

Last year, a hospice medical director in Pennsylvania, was convicted of Medicare fraud for false certifications of the clinical eligibility of patients for hospice care. The wrongdoing involved appears to be fairly black and white. However, another more nuanced area of regulatory oversight of physicians is looming on the horizon. This is focused on the requirement that the certifying physician has either reviewed the patient’s record, or examined the patient prior to composing the physician narrative for the certification of terminal illness. Claims are currently being disallowed on the basis that evidence is lacking to show that the certifying physician actually reviewed the patient’s record, if that physician did not examine the patient him or herself.

The relevant language, from Subpart B of the Medicare hospice regulations is as follows:

§ 418.22 Certification of terminal illness.

(b) Content of certification

(2) Clinical information and other documentation that support the medical prognosis must accompany the certification and must be filed in the medical record with the written certification as set forth in paragraph (d)(2) of this section. Initially the clinical information may be provided verbally, and must be documented in the medical record and included as part of the hospice’s eligibility assessment.

(3) The physician must include a brief narrative explanation of the clinical findings that supports a life expectancy of 6 months or less as part of the certification and recertification forms, or as an addendum to the certification and recertification forms.

(iii) The narrative shall include a statement directly above the physician signature attesting that by signing, the physician confirms that he/she composed the narrative based on his/her review of the patient’s medical record, or if applicable, his/her examination of the patient. (emphasis added)

Let’s unpack the italicized portion of the attestation and address how to assure compliance:

The certifying physician must compose the narrative, which is a summary statement of the medical information supporting and explaining the physician’s determination of the terminal prognosis, and clinical eligibility, of the patient to be certified. This is based on information/patient data, which must be documented in the clinical record.

The regulations allow for verbal information initially, but are clear that this then needs to be documented in the patient’s record.

The physician narrative should contain language that references the findings of the face-to-face (F2F) encounter, if applicable (whether performed by a nurse practitioner, non-certifying physician, or certifying physician).

§Example: I have reviewed the findings of the nurse practitioner’s F2F encounter of 4/15/2015, which paint the picture of a severely dyspneic, oxygen-dependent patient, limited to bed-to-chair transfers.

The physician narrative should contain language referencing relevant findings of any physician examination of the patient (whether performed by a non-certifying physician, or the certifying physician).

Any inconsistencies in the clinical record (e.g., conflicting assessments of the patient’s structural, functional, and/or activity level; FAST, KPS/PPS score; BMI) that might bear on prognosis need to be addressed in the physician narrative.

References to the source of supportive information from Interdisciplinary group (IDG) assessments can be included in the narrative.

§Example: The team social worker notes of 02/04/2105, state that “ Mrs. S. appears weaker than my last visit 3 weeks ago, and is now bedbound”.

The certifying physician can include language from the regulatory mandate within the narrative itself.

§Example: Mrs. S is an 89-year-old female with cerebral atherosclerosis with the secondary condition of vascular dementia. On my review of the medical record, Mrs. S’s decline is demonstrated by…

IDG documentation should reflect all information sharing (verbal and written) with the certifying physician, whether in meetings or through other communication channels (e.g., phone calls, emails).

The attendance of the certifying physician at the IDG meeting does not, in itself, satisfy the requirement for review of the patient’s medical record.

Physician narratives should include language that evidences medical record review.

If the certifying physician has personally examined the patient, then the letter of the law of the attestation statement has been fulfilled. Best practice would seem to dictate that, even in this case, the medical record should be reviewed and contribute to the decision-making process and narrative composition by the certifying physician.

Remember, the signed attestation is required for technical compliance, but must be supported by evidence within the narrative of review of the medical record, or examination of the patient, by the certifying physician!

If there are any best practice recommendations or experiences you have had that would add to this discussion, please share so all may benefit!

]]>Hospice Prognosis vs Diagnosis - Can we slow down for a minute please?compliancePart DHeather Wilson, PhDFri, 03 Apr 2015 01:16:26 +0000http://weatherbeenetwork.net/blog/2015/4/2/prognosis50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:551d7c9ee4b0f86de55e0499I had not been paying much attention to NHPCO's flurry of activity during
March regarding prognosis vs. diagnosis until I received an email from a
well-respected hospice CEO that said, in part:
"Our Medical Director is livid and is adamant that what 'influences' the
prognosis is very different from what is "related to" the prognosis. This
seems like a fundamental shift from what we have been doing for thirty
years - is it possible that everyone (including NHPCO) has been so wrong
about this? We think we have financial challenges now - just wait!"

I had not been paying much attention to NHPCO's flurry of activity during March regarding prognosis vs. diagnosis until I received an email from a well-respected hospice CEO that said, in part:

"Our Medical Director is livid and is adamant that what 'influences' the prognosis is very different from what is "related to" the prognosis. This seems like a fundamental shift from what we have been doing for thirty years - is it possible that everyone (including NHPCO) has been so wrong about this? We think we have financial challenges now - just wait!"

Needless to say, that email caught my attention and I delved further. That CEO has good reason to be worried and to question.

To summarize NHPCO's position:

Hospice providers must reframe how they characterize patients and shift from a single diagnosis to a more comprehensive view that utilizes all diagnoses and conditions that contribute to each patient's terminal prognosis.

In making this shift, providers need to ask the question "Does this diagnosis or condition contribute to or influence the patient's terminal prognosis?" If the answer to the question is yes, it becomes the hospice's responsibility (including financial).

In other words, NHPCO has adopted CMS' non-regulatory contention from the preamble to the first hospice regulations in 1983 (raise your hand if you read that preamble or any other in your life!) that "it is our general view that hospices are required to provide virtually all the care that is needed by terminally ill patients" and their further statement that "unless there is clear evidence that a condition is unrelated to the terminal prognosis, all services will be considered related."

That preamble ramble had not resurfaced until 2013 when the whole Part D brouhaha (love that word) reared its ugly head. As I recall at the time, NHPCO was pretty upset with the "virtually all" statement and CMS' renewed emphasis on this 30-year-old non-regulatory statement as justification for slamming the hospice industry on Part D payments.

I don't know what changed, but NHPCO gives three reasons for why hospices need to adhere to this cultural shift or "new paradigm" of how hospices should characterize, think about, document and pay for hospice patients:

This is nothing new, the emphasis has always been on prognosis;

If hospices don't do this it is likely CMS will subject the industry to even more draconian measures; and

It is the right thing to do.

Let's unpack/discuss each of these reasons.

1. This is nothing new, the emphasis has always been on prognosis

Not really. Yes, the hospice statute and regulatory text defines hospice eligibility as a patient having a terminal prognosis of 6 months or less. And yes, CMS can pull its relatedness statements out of a 30-year-old non-regulatory preamble to the original hospice regulations and restate it in 2013 as proof it has always been this way.

But it begs the question - Why wasn't this an issue for CMS 20 years ago? 10 years ago? Even 5 years ago? Could it be that since hospice is no longer "budget dust" (although when you consider the total budget it still pretty much is), CMS needs to revive the old thinking that maybe made sense in 1983 but hardly makes sense or is even feasible today? CMS needs to protect the Medicare Trust Fund - that is its job. But, unfortunately, like most insurance companies, it wants to pay for as little as possible.

Back to the issue at hand, the hospice industry has pretty much forever focussed on the patient's terminal diagnosis, his or her terminal illness. Hospices have not done this capriciously nor to narrow their scope of responsibility. Rather, there is very clear regulatory text to support the focus on the patient's terminal illness/diagnosis. In 418.22(b) regarding the content of the certification of terminal illness, it states:

(b) Content of certification. Certification will be based on the physician’s or medical director’s clinical judgment regarding the normal course of the individual’s illness. The certification must conform to the following requirements: (1) The certification must specify that the individual’s prognosis is for a life expectancy of 6 months or less if the terminal illness runs its normal course. (emphasis added)

It does not say here "terminal illnesses" (i.e., plural) or "terminal illness and co-morbid conditions" or "terminal illnesses and EVERYTHING ELSE THAT COULD POSSIBLY INFLUENCE IT."

"Over decades of practice in our field, some hospice programs have tended to characterize their responsibility to patients by a single diagnosis, as evidenced on Medicare claim forms."

I would suggest that rather than "some" hospice programs it is more likely most, if not all, hospice programs have focused on a single or principal hospice diagnosis. I would further suggest that this single diagnosis focus has been in response to dealing with LMRP/LCD guidelines, industry teaching, and nobody telling hospices, until now, that they were supposed to focus on prognosis and EVERYTHING, instead of just the patient's terminal illness.

So no, it has not always been this way. Neither CMS nor NHPCO can all of a sudden say "Hey, we told you thirty years ago what you were supposed to do and even though we never cared that you didn't do it before, you had better do it now or...." Good segue to the next point...

2. If we don't do this now, it will be worse later

Apparently NHPCO is having/has had a lot of intense conversations with CMS and CMS is pleased with the "proactive" efforts of the hospice industry with regard to the prognosis issue. I don't know what they are saying but it sounds as if CMS is threatening worse things if the industry does not fix this issue. Don Schumacher said in his March 5th message:

"Let me be very clear here, by being more proactive with regards to hospice's responsibility, we are likely to avoid CMS implementing more draconian changes, changes that might be far more challenging for us to deal with."

At least there is an implicit acknowledgement that what NHPCO is advocating is "draconian" although less so than what CMS might have in store for hospices. It sounds like a threat and/or a promise. I don't know where to go with that but I do know that threats can be infantilizing and demoralizing.

3. It is the right thing to do

I saved this one for last because it is the big elephant in the room. First, however, hospices do not need to be "shamed" into doing the right thing. There are very very few hospices that are not out there everyday wanting and trying to do the right thing - with limited resources and intense scrutiny.

But to discuss this further, we may need to harken back to the 90s and question what "it" is. If "it" is taking care of the whole patient and everything the patient needs to ensure safe, effective and comfortable end of life care then yes, of course, that is the right thing to do. If "it" is focusing on everything that could possibly "influence" or "contribute" to a patient's terminal prognosis, in order to broaden the scope of the hospice's financial responsibility, it is very, very questionable if that is the right thing to do and if it is even feasible.

The elephant in the room here is how are hospices supposed to afford this significant paradigm shift from diagnosis to the all-inclusive prognosis? NHPCO simply states: "Yes this is likely to increase our responsibilities in a number of ways, but it is the right thing to do." That may be the understatement of the year with regard to the financial implications of this shift.

When the Medicare Hospice Benefit was conceived in the early 80s, most hospice patients had a primary diagnosis of cancer with a relatively predictable disease trajectory and relatedness determinations were more straightforward. As hospice has evolved over the years, hospice has broadened access to patients with more complex terminal diagnoses, disease trajectories and needs. What CMS and NHPCO are saying, essentially, is that not only do hospices have to provide patients with everything already included in the Medicare Hospice Benefit, but hospices need to accept full financial responsibility for everything that contributes to or influences (and is therefore related) to the patient's terminal prognosis and that, with few exceptions, everything is related. I am not an economist and I don't know what the per diem for routine home care was back in the 80s in terms of today's dollars. I do know that the hospice CEO who sent me that email gets less than $140/day to provide everything for patients cared for by their rural hospice. I also know that most hospices have slim margins, have already been trying to survive with reimbursement cuts and are barely making it. This will likely be an administrative, financial, clinical and compliance nightmare for most hospice programs.

The way it was supposed to work with the Medicare Hospice Benefit's fixed, per day, per level of care, prospective payment structure was that costs would be spread across a hospice's entire patient population so that "expensive" patients could be mitigated by "less expensive" patients. That does not work anymore and hasn't for a long time. First, with this new paradigm, all patients are likely to be expensive patients. Second, it used to be that longer length of stay patients could help spread the costs but in recent years, hospices have been subjected to unprecedented scrutiny for patients with a length of stay close to or longer than 180 days. The message, loud and clear, is hospices better not have long length of stay patients.

Increasingly, hospices are in a no win situation because the Medicare Hospice Benefit was designed in the 1980s and does not work in 2015. To wit:

No other part of the health care continuum is required to provide bereavement services with no reimbursement;

No other part of the health care continuum is required to recruit, train and manage enough volunteers to provide at least 5% of patient care hours;

No other part of the health care continuum is required to meet professional management responsibilities that include the virtually impossible task of maintaining control of a patient's plan of care even when the patient is being cared for in an entirely unrelated institution like a hospital or nursing home;

No other part of the health care continuum is required to maintain a sufficient number of employees to provide 24 hour care in a patient's home in the event that maybea patient will need it rather than contract for additional help when needed; and

No other part of the health care continuum is required to pay for everything possibly related to a patient's prognosis out of a meager per diem payment.

I am not advocating throwing the baby out with the bath water. Rather, doesn't it seem like energy and resources would be better spent advocating for a revised Medicare Hospice Benefit that makes sense for the financial and clinical realities of 2015? Evidence suggests that mandated hospice payment reform is likely to increase provider burdens, and not do much or anything to address the aspects of the Medicare Hospice Benefit that make the provision of hospice care inordinately and unnecessarily complicated and impractical.

Is this focus on an all-inclusive prognosis another (or final) nail in the hospice coffin for many smaller hospice programs? Is the hospice industry -- as we have known and loved it -- on track go the way of the nursing home and funeral industries: consisting predominantly of large, for-profit chains because they are the only ones that can afford to exist?

]]>The Hospice Times They Are A-Changin....Heather Wilson, PhDSun, 15 Feb 2015 16:38:11 +0000http://weatherbeenetwork.net/blog/2015/2/14/a-changin50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:54df64e2e4b08bab4fb6c2a5One of my favorite nuns in high school often called me "bold" (a frequent
nun term) and accused me of taking too much pleasure in "starting
revolutions." For this blog post, allow me to be bold and describe a
revolution I see occurring in the hospice industry. I did not start it, I
don't even take pleasure in it - but I want to name it.

Come gather ’round peopleWherever you roamAnd admit that the watersAround you have grownAnd accept it that soonYou’ll be drenched to the boneIf your time to you is worth savin’Then you better start swimmin’ or you’ll sink like a stoneFor the times they are a-changin’

Bob Dylan

Introduction

One of my favorite nuns in high school often called me "bold" (a frequent nun term) and accused me of taking too much pleasure in "starting revolutions." For this blog post, allow me to be bold and describe a revolution I see occurring in the hospice industry. I did not start it, I don't take pleasure in it - but I want to name it.

To explain what I am thinking about, let me use a framework loosely adapted from Thomas Kuhn's seminal work, The Structure of Scientific Revolutions. Despite later critiques and expansion of Kuhn's theory, as well as the overuse if not abuse of the term "paradigm shift," I find his description of how science evolves to be a useful framework for understanding how change occurs.

Briefly, it is like this: there is an existing (or old) paradigm that is basically the commonly accepted world view, the status quo, the way things are. Then, gradually, or all of a sudden, there are anomalies - things that occur that challenge the existing paradigm. The anomalies can cause a crisis or a revolution to occur - with some people defending the existing paradigm and others seeking to embrace a newparadigm that may be emerging. (And there are likely still others who are oblivious to the whole thing going on :). Depending upon the strength of the existing paradigms or the strength of the anomalies, the status quo is maintained or there is a paradigm shift and a new paradigm emerges.

Thank you for bearing with me. Now let's look at what this has to do with the hospice industry.

The Old (Existing) Hospice Paradigm

We have a unique, much loved and revered history. The hospice movement was volunteer and community-based, mission-driven, not-for-profit and holistic. Some snarkily refer to these as the granola bar, Birkenstock days, but they were heady times as hospice made tentative steps toward the mainstream with the promulgation of the Medicare Hospice Benefit. As the hospice "movement" grew and gradually, if reluctantly, became accepted as an "industry," it was nevertheless an industry that continued to be revered. Hospice workers are/were generally seen as "angels of mercy," a "Godsend," and the most frequently heard family comment is/was, "Why didn't we come to hospice sooner?" Hospices rejoiced at being allowed to increase access to patients in nursing homes and bemoaned the short lengths of stay that did not allow patients and their loved ones to reap the full benefits of hospice care. In the beginning, hospice regulations seemed optional, but then, gradually, especially with the "new CoPs" in 2008 and the increase in ADRs and payment scrutiny, regulations have been taken more seriously. But it was/is all, for the most part, good.

Anomalies

We could say that the first anomaly to challenge the hospice paradigm was Operation Restore Trust back in the 90s. But that was merely a blip compared to now. Let's consider the following recent anomalies:

The best decision we made was parting ways with Hospice. My mother's health improved rapidly with at-home care with an agency focused on quality-of-life for older persons.

We sincerely hope that no one ever has to go through the traumatizing ordeal that my sister and I went through as our father was dying while in hospice.

[A not for profit hospice in Florida] was so non-performing when my husband's oncologist put him in their care that it was almost criminal.

My experience with hospice care for my mother was not pleasant and I was dealing with one of the first hospice organizations in the United States ...

My Dad was tortured by hospice.

Disturbing (if not horrifying) statistics such as:

Hospices typically provided fewer than 5 hours of visits per week and were paid about $1,100 per week for each beneficiary receiving routine home care in an ALF [finding from a recent OIG report on hospice in ALFs]

18% of U.S. hospices did not provide a single day of continuous care or general inpatient care (both entitlements of and required by the Medicare Hospice Benefit) [based on a Washington Post analysis of 2012 billing records for 2,560 hospices in the US]

Under the care of 12% of hospices (445), a third or more of patients die without receiving a skilled visit in the last 48 hours of their lives. At 34 of those hospices, no patient saw a skilled nurse during that time [based on internal Medicare findings reported by Jon Blum at an NHPCO conference in March 2014].

See this page from the Caring Foundations website for a comprehensive timeline listing of hospice layoffs and closures or download your own pdf copy here

Crisis / Revolution

Wasn't that depressing? Yes, it is, but it is much more than that. I believe these recent anomalies have precipitated a crisis/revolution that challenges the existing/old hospice paradigm and is calling for a new paradigm to emerge or indicating that, in fact, it already has.

At the risk of being too simplistic, here is what we have been hearing about the anomalies noted above:

"We just need more oversight and transparency. Some hospices have not been surveyed for 10 years. Oh yay! Now we have the IMPACT Act which will increase survey frequency to every three years. Everything will be ok. Let's focus on survey readiness."

"It is those darn for-profits. If it weren't for them running hospices like a business and focusing on margins instead of mission we would not be in this mess. We should report them and get them in trouble."

"That journalist writing all those horrible articles is just trying to win a prize."

I hate to be rude (or a revolutionary), but the IMPACT Act ain't gonna have much impact (see my previous blog post on this). And while a significant number of for-profits have been cited for quality concerns, they can't be blamed for the quality issues raised by regulators and family members served by a significant number of not-for-profit hospices. And, also, the for-profits are part of the new paradigm and they are here to stay, so let's get over it.

The questions I want to consider and that I do not hear much about include: What are these anomalies telling us? What can we learn from them? How are we being challenged? Are we already in a new paradigm and don't know it/won't accept it? If a new paradigm is emerging, what does it look like, and how different is it from what we have known? Has the quality of hospice care really deteriorated? How widespread is consumer dissatisfaction with hospice? Are the quality measures currently used by hospices (for example, in the Hospice Item Set) helping at all to improve the quality of care provided by hospices? What will the hospice industry look like in 5-10 years and will whatever it looks like be by default or directed by those who have embraced the new paradigm?

I don't know the answer to those questions. I have some thoughts about them but no definitive answers. I am worried about the variability in the quality of care provided by hospices (both for-profit and not-for-profit). I am worried that public trust in hospice is eroding. I am worried that the emphasis on survey readiness shifts focus and resources away from performance improvement to avoiding punishment. I am worried that many hospices, both for-profit and not-for-profit, may not actually know how to do "the right things right" or, worse, even know what the right things are.

Kuhn says that change is inhibited by the lack of freedom to question, as well as the unwillingness to experience the discomfort of living in the tension between two paradigms. I believe we need to question and we need to have open, far-reaching conversations that do not include defensiveness or finger-pointing. We need to authentically face the challenges of the anomalies and focus on improving the quality of care provided by all hospices and determine what needs to be done to regain public trust.

]]>OIG Recommends Greater Scrutiny for Hospice Services Furnished to Patients in ALFs Howard Young, Esq.Thu, 15 Jan 2015 20:43:24 +0000http://weatherbeenetwork.net/blog/2015/1/15/oig-jan1550f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:54b815c6e4b054d2822e22deThe evaluation and policy division of the HHS Office of Inspector General
(OIG) issued a study dated January 13, 2015 after evaluating all Medicare
hospice claims from 2007 through 2012. If history is a guide, critical OIG
studies such as this one trigger additional targeted scrutiny, and so
hospices, particularly for-profit hospices, should expect increased hospice
audits related to their services to ALF residents. What Should Your Hospice Do?

The evaluation and policy division of the HHS Office of Inspector General (OIG) issued a study dated January 13, 2015 after evaluating all Medicare hospice claims from 2007 through 2012. OIG’s general study observations were that:

Hospices provided care much longer for beneficiaries in assisted living facilities (ALFs) as compared to other settings like nursing facilities, private homes and SNFs;

ALF residents often had diagnoses that usually required less complex care;

Hospices typically furnished fewer than 5 hours of visits for routine home care patients in ALFs; and

Ultimately, OIG, like MedPAC before it, recommends to CMS that its hospice payment reform should address the financial incentives under the current system to target ALF residents for hospice services.

If history is a guide, critical OIG studies such as this one trigger additional targeted scrutiny, and so hospices, particularly for-profit hospices, should expect increased hospice audits related to their services to ALF residents. Indeed OIG’s study recommends that CMS “target certain hospices for review.”

One important point the OIG study does not address is the simple observation that residents of ALFs are generally more likely to be healthier than residents of nursing homes and SNFs and so you would expect a lower median number of hospice days for patients in those non-ALF settings. Nonetheless, with the OIG findings that “hospices provided care to beneficiaries in ALFs much longer than to beneficiaries in any other setting” and “Medicare paid twice as much for care for beneficiaries in ALFs than for beneficiaries in other settings,” the OIG’s call for scrutiny of hospice care furnished in ALFs is, as a practical and policy matter, unavoidable. Hospices should take note.

So what are the takeaways of this latest OIG hospice study?

If you are a for-profit hospice, you will likely face a higher level of scrutiny than your non-profit peers. This for-profit hospice “call out” is consistent with prior OIG hospice reports that have done the same.

If your hospice serves a disproportionate or high number of ALF residents (identified by OIG in its study as hospice that had more than half of their Medicare payments from care provided in ALFs), you are more likely subject to Medicare review.

OIG recommendations to CMS for hospice payment reform, greater transparency on hospice payments, and better data for hospices to compare themselves against their peers (all of which CMS agreed with), will likely be adopted in the future. But hospice reform has been on CMS’s Affordable Care Act “to-do” list since 2010 and those reform wheels can turn slowly.

In the meantime, hospices should look to see if their ALF resident data looks different in 2015 than it did three years ago in 2012, the last year covered by OIG’s study. If not, it makes sense to consider potential compliance assessments of its services furnished in the ALF setting.

For any individual hospices with a disproportionate number of ALF residents (i.e., greater than 50%), consider an appropriately focused compliance review to assess potential risk, particularly if your hospice has cap liability and a higher than average length of stay.

While in the current program integrity focused environment, CMS and OIG audits may be an inevitable part of participating in the Medicare program, it is important to pay heed to the government’s clear signals of the increased scrutiny that lies ahead and to get out ahead of auditors by engaging in appropriate internal assessment and, as appropriate, process improvement.

]]>Part II. Appreciative Inquiry and the Certification Process…Imagine That! Discovery and DreamSuzanne Karefa-Johnson, MDWed, 17 Dec 2014 16:57:05 +0000http://weatherbeenetwork.net/blog/2014/12/9/ai-part-ii50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:54871af0e4b0dafc24fe4718Years of experience and research have demonstrated that “…people learn, and
organizations change most readily when they focus on, study, and engage in
dialogue about strengths, patterns of success and who they are at their
best."

Interdisciplinary group (IDG) members are encouraged to let their imagination and creativity run loose and give voice to their highest vision of the coordinated interdisciplinary delivery of care;

Each IDG meeting is an energized and passionate experience with innovation, collaborative thinking, and anticipatory planning focused on achieving the patient and family goals of care; and

The documentation of clinical information reflects a multidimensional, integrated and cohesive picture of the dynamic nature of the patient’s terminal illness, related conditions and the palliation of total pain.

For those of you who have already achieved this, congratulations! Please share with us your pathway(s) to success! For the rest of you, please read on…

Appreciative Inquiry

Appreciative Inquiry (AI),is a transformational process that seeks not to identify problems and construct solutions, but to embrace the understanding that organizational change is rooted in, and energized by, the innate strengths and capabilities that have carried it thus far -- its positive core. AI is built upon the premise that the process of asking positive questions shapes the creative conversations that generate a shared vision of the future and the design. Years of experience and research have demonstrated that “…people learn, and organizations change most readily when they focus on, study, and engage in dialogue about strengths, patterns of success and who they are at their best.[i]” Research has demonstrated that AI lends itself to a variety of scales of involvement from small groups (e.g., teams) to whole organizations to large gatherings known as AI summits.

What led to this new way of thinking about organizational change and the move from deficit thinking to the exploration of innate strengths as a springboard to possibility? Sue Annis Hammond outlines the 8 Assumptions of Appreciative Inquiry[ii]

“In every society, organization, or group -- something works.

What we focus on becomes our reality.

Reality is created in the moment, and there are multiple realities.

The act of asking questions of an organization or group influences the group in some way.

People have more confidence and comfort to journey into the future (the unknown) when they carry forward parts of the past (the known).

If we carry parts of the past forward, they should be what is best about the past.

It is important to value differences.

The language we use creates our reality.”

This is not “pie in the sky” thinking or a process that denies the existence of problems. It is a reorientation of how an organization chooses to approach its development. Rather than looking for what is broken, the focus is on finding what is working and using that as a foundation for creating more of the same. Sound familiar? Remember Dame Cicely Saunders’ famous quote about hoping to “help the dying to live until they die, and their families to live on”? Looks to me like hospice and AI already swim in the same pool!

I. The Affirmative Topic Choice

The process begins with the selection of the topic choice. From the beginning of any meeting or process, the premise is informed by the framing of the topic. For example, rather than trying to solve the problem “inconsistent and incomplete documentation,” in the AI process, the affirmative topic for inquiry could be framed as “deliberate descriptive documentation.” The topic of choice becomes the focal point for inquiry and the 4-D cycle begins.

II. The 4-D Cycle

Each of the 4 phases of the AI cycle can be summarized by the following affirmative questions:

Discovery: “What gives life?”

Dream: “What might be?”

Design: “What should be?”

Destiny: “What will be?”

Discovery

“The best of what is” – Appreciating

This stage aims to uncover past and present strengths and successes of the group through asking positive questions. What gives life to the system? Stories emerge illuminating experiences of which both individuals and the group can be proud. There is validation of the inherent “best” that already exists.

Questions are constructed to encourage storytelling, such as:

Describe a time when you felt most engaged with the IDG and proud to be a member of the team.

What were the circumstances that made you proud? What effect did that have on your work? On the next team meeting?

What is at the heart of the IDG -- that thing that most defines who you are as a team, and without which the team could not survive?

Tell us about an example of successful collaboration with another team member that you experienced recently. What did you do to contribute to this collaboration? How did this make you feel? What did you learn from this experience?

What emerges from this stage is the positive core – the strength, resiliency and successes that is the team’s shared history. These are the qualities, competencies and practices that will remain, even as change occurs. Recalling these experiences, team members are energized as they move into the next phase.

Dream

“What might be?” – Envisioning

Through attention to the stories that emerged in the discovery of the “best of what is,” and through the use of imagination, in this phase, team members explore their hopes for the future. The process of affirmative inquiry continues:

It is 2018 and your team has been voted the “ideal IDG” – a best practice model of interdisciplinary coordination, collaboration and communication.

Describe in as much detail as you can what makes this 2018 team exceptional. As you walk into IDG:

How is the room arranged?

What is the structure of the meeting?

What kinds of conversations are transpiring? Between whom?

What do you recognize that is present in your IDG today?

What is different?

If you could have 3 wishes that would increase the vitality of the IDG, what would they be?

You have the opportunity to work with an information technology (IT) expert to build an electronic medical record. What would be most important to you? Why?

This is a time for unbridled dreaming with creative thinking encouraged through the use of conversation, writing, drawing and drama.

What emerges from this stage is a collective vision of the future -- a shared dream.

Energized by the positive core and dreaming of what might be, the group is ready to move into the next phases in the co-creative process. Design and Destiny, found inPart III of this blog series.

]]>Part III. Appreciative Inquiry and the Certification Process…Imagine That! Design and DestinySuzanne Karefa-Johnson, MDWed, 17 Dec 2014 16:56:34 +0000http://weatherbeenetwork.net/blog/2014/12/12/ai-part350f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:54872e6be4b027745c1dc1e7Through collaborative thinking, the team chooses innovative processes that
are in alignment with both the strengths identified in Discovery and the
imagined hopes of the future (Dream).

“Whatever you can do or dream you can, begin it. Boldness has genius, power and magic in it.” - Goethe

Be sure to read Part I and Part II of this blog series before reading this final post.

Design

“What should be?” – Co-constructing

Through collaborative thinking, the team chooses innovative processes that are in alignment with both the strengths identified in Discovery and the imagined hopes of the future (Dream). As an example, the group may focus on enhancing collaboration by devising ways to expand the “voices” and representation at the IDG “table” (e.g., hospice aides, volunteers, patients and families).

Questions during this design stage of the process might include:

What is in place to keep the IDG on the right track?

How has the team leader and every team member supported these achievements?

What are the characteristics of the IDG’s most supportive and productive members?

What is the best thing the IDG has put in place to support these achievements?

What emerge are provocative propositions that bridge the best of what is (Discovery) with what might be (Dream). These are bold, affirmative statements. For example:

“The Dream IDG is a passionate, committed, coordinated and integrated group united in our focus on achieving the patient/family goals of care through our dynamic and collaborative plan of care. We exist outside of fixed times, space or agendas. Communication is constant, collaborative and courageous. Our exceptional care in meeting the patient/family needs is captured in detailed descriptive documentation of every aspect related to the terminal journey and the palliation of total pain.”

Destiny

“How to empower, learn, and adjust/improvise” – Sustaining

This final phase of the Appreciative Inquiry (AI) process involves a commitment from members of the IDG to implement the steps needed to create the envisioned future. The questions are framed to engage the team in imagining they are looking back at the previous three years and recalling how they were able to become the Ideal IDG (see Part II). Questions to ask include:

What type of goals did the IDG establish to achieve the 2018 “ideal IDG” award?

What allowed the goals to engage the IDG?

What were the one or two essential actions the team took and you as a team member took to achieve the team’s goals?

How has the IDG maintained its positive progress?

The AI process results in new ways of seeing our teams, our organization, our world, and ourselves. This generates new ways of being and doing based on relationships and connections.

What has excited the team most in the AI process? What visions do they hold for sharing this with others? Inspired by the progress there is the energy generated by continuous learning, adjustment, improvisation and innovation, leading back into the 4-D cycle. This is the sustaining stage.

III. Application

There are many ways to engage in this process - its beauty is in its adaptability. The Corporation for Positive Change, an internationally recognized leader in AI, recommends the use of paired interviews followed by group discussion to fully engage the entire group in the process. A sample agenda might include:

Overview of the process.

Paired interviews – Discovery. Participants take turns asking all the Discovery questions and writing down their partner’s answers. The team then switches places with the 2nd person asking the partner the same question.

Group discussion – Discovery. Participants share 1 brief highlight from their partner’s response to each question.

Paired interview – Dream (same process as above).

Group discussion – Dream (same process as above).

Paired interview – Design.

Group discussion – Design.

Paired interview – Destiny.

Group discussion – Destiny.

Common themes.

Next steps.

It is not necessary to go through all the stages of the 4-D cycle at once or even at all to benefit from the power and possibility of AI. Nor do you necessarily need a skilled facilitator to get started. Find ways to introduce positive questions into the IDG. Begin to reframe problems into “possibilities” that have yet to be discovered. Celebrate successes and share the stories. Trust the process; it has a life of its own. And the rest…well that will be your story!

IV. Conclusion

This blog series provides a brief and simple introduction to AI. For those interested, there are multiple resources for in-depth education online and in print. The Appreciative Inquiry Commons provides education and the sharing of information and tools about the AI process. Materials on that site informed much of this blog.

]]>Part 1: Appreciative Inquiry and the Certification Process... Imagine that!compliancePhysicianSuzanne Karefa-Johnson, MDThu, 27 Nov 2014 10:15:00 +0000http://weatherbeenetwork.net/blog/2014/11/25/part-1-ai-certification50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:5474e63ee4b09b8c7c677f36Every hospice physician has experienced difficulties in assessing “gray”
patients. These are the ones who, at admission, do not have a principal
diagnosis or terminal story that leaps out from the record, although for
many of these patients, the physician is able to answer “no” to the “would
you be surprised if your patient dies within the next six months”
question.
* Are these patients truly terminally ill?
* Is a period of seeming stabilization sustainable?
* Should these patients be evaluated for discharge due to extended
prognosis?

Part I: The prognostication conundrum

Challenges

There has certainly been a good bit of negative press about hospice in the media in the recent past. Adding insult to injury, in early November the story broke about a hospice medical director in Pennsylvania who was convicted for “falsely certifying that patients were appropriate for hospice care.”[i] Yes, there are bad apples in the bunch. However, the vast majority of hospice medical directors are committed, passionate physicians who take their role and responsibilities very seriously.

The focal role of determining clinical eligibility for the Medicare hospice benefit is not an easy one. Day by day, the hospice medical director has to navigate the complex world of prognostication, especially for the frail elderly with organ system failure. The 2014 NHPCO Facts and Figures: Hospice Care in America showed an upward swing in the top three non-cancer principal diagnoses -- dementia, heart disease and lung disease and an increase in the average length of service.[ii]

Prognostication

Prognosis is both an art and a science. Physicians tend to overestimate the probability of survival.[iii] Prognostication has not been a priority area for research nor has it been adequately addressed in medical education and training. The existing tools are limited in their predictive accuracy. Every hospice physician has experienced difficulties in assessing “gray” patients. These are the ones who, at admission, do not have a principal diagnosis or terminal story that leaps out from the record, although for many of these patients, the physician is able to answer “no” to the “would you be surprised if your patient dies within the next six months” question. These are the patients who, while further along the continuum, are not evidencing clear-cut or rapid decline. Some of these patients experience the “hospice cure” as a result of the great care provided by the hospice team.

Are these patients truly terminally ill?

Is a period of seeming stabilization sustainable?

Should these patients be evaluated for discharge due to extended prognosis?

These are the patients over whom there may be team disagreement, discouragement and even disillusionment – the “tough” patients. Added pressures of heightened external scrutiny and the internal pressures of census growth further compound the uneasiness.

IDG

Within this very prognostication conundrum lies the opportunity for the unique strengths of hospice to shine. The interdisciplinary group (IDG) is at the core of hospice and adds immeasurable value in the delivery of end-of-life care. The IDG addresses patient and family-specific goals through an individualized plan of care. It seeks to palliate “total pain” -- whether expressed through physical, psychosocial, spiritual, or financial symptoms. The diversity and expertise of the group facilitates individual and collective storytelling at its best. It is a dynamic system based on diversity, trust, conversation, collaboration, interdependence, and integration.

Although the hospice physician bears the singular responsibility for the determination of clinical eligibility, certification and narrative composition, these are the final outcomes of a process dependent on other members of the IDG and admission team. To be able to paint the picture, the physician must build on the information shared by the team, both in the IDG meetings and through the medical record. Seen through the eyes of the different disciplines, the full story of the terminal illness can unfold.

Scrutiny

Both the internal and external environments in which hospice exists are becoming increasingly more complex. The quality and reliability of documentation in the clinical record has a big part to play in ensuring payment for services rendered. The physician narrative, as part of the certification process, has a key role in this. “Not hospice appropriate” was the top denial reason code for Palmetto GBA in July- September of this year. “Physician narrative statement not present or valid” was ranked third.[iv]

Opportunity

Patients who fall into the gray category will continue to be referred. For those who are determined to be terminally ill, there is no greater gift than hospice. These patients are challenging the system to evolve in response to the increasing burden of chronic illness and the difficult and unclear transition to endoflife. They are depending on hospice for ongoing growth and transformation to ensure that they not only receive excellent palliation to relieve their total pain, but that the care provided can be justified through documentation that supports clinical eligibility.

Appreciative Inquiry

So…

What does it look like when the IDG is functioning at its best?

What is it that energizes, motivates, inspires, and gives life to the team?

What has worked well in the past during team discussions of complex patients?

Questions like these arise from the assumption that the development of a system will be shaped by where it chooses to place its focus and the kinds of questions it asks itself. They are not lofty or wishful thoughts, but part of a paradigm for change that seeks to uncover the “best of what is,” tapping into the creative energy of the positive to drive innovation that is inspired, hopeful and energized. There is appreciation and encouragement for what emerges when the focus is on strengths, rather than problems. This process is called “Appreciative Inquiry” (A.I.) and at its core is the “Four-D cycle” of Discover, Dream, Design, and Destiny. [v]

Stay tuned for insights into how the A.I. process can inform our certification process!

]]>OIG Hospice Audit – Despite Extremely Low Error Rate, OIG Claims Significant Refund Liability on Basis of ExtrapolationOIGHoward Young, Esq.Wed, 19 Nov 2014 17:40:11 +0000http://weatherbeenetwork.net/blog/2014/11/19/oig-audit-liability50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:546c810de4b03f89760db8f6The OIG clings to its tenuous position that, even with its concession that
CMS will determine the overpayment amount, the hospice was overpaid “at
least $447,467.” This suggests OIG is driven to show Congress that it will
continue to “come down hard” on hospices, even those with very low error
rates. In an audit posted by the HHS Office of Inspector General (OIG) on October 9, 2014, the OIG reported on its audit of 100 randomly selected beneficiary-months from The Community Hospice, Inc., a New York hospice, related to an audit universe of 9,147 beneficiary-months. OIG, working with Medicare Administrative Contractor (MAC) NGS for clinical record review support, found that 93 of the 100 beneficiary-months met Medicare criteria, but that 7 months did not. The hospice disagreed with that finding for 3 of the beneficiary-months and refunded Medicare payments for 4 of the beneficiary-months.

With the ultimate error rate remaining in legitimate dispute based upon a number of legal arguments advanced by the hospice as well as disagreement whether appropriate documentation supports the claims, OIG observed that CMS “will reexamine all cases that we [OIG] have recommended disallowing and determine whether an overpayment exists and if the limitation of liability provisions apply.” (OIG Audit Report A-02-11-01016, p. 6.) In other words, OIG concedes that whether overpayments actually exist for the 3 beneficiary-months in dispute will be left to CMS. With a financial error rate of 5.62% at the high end (if the hospice does not prevail on its appeals) and 2.68% at the low end (if the hospice does prevail), the hospice argued that OIG should not seek to extrapolate its findings to the universe when reporting its findings. The hospice cited to the Medicare Program Integrity Manual that prohibits Medicare contractors from extrapolating audit findings in the absence of a high or sustained level of payment error or if the contractor has provided educational intervention previously that failed to correct the error rate. Remarkably, OIG dismisses that argument stating it is not bound by CMS rules since OIG is not a CMS contractor. So instead of crediting these arguments, OIG stood pat on its original findings, estimated that the hospice “received at least $447,467 in Medicare reimbursement for hospice services that did not comply with certain Medicare requirements” and recommended that the hospice refund that extrapolated amount to Medicare.

What is The Significance of This OIG Audit Report?

OIG consistently recommends in its audit reports where statistical sampling is employed that the providers refund to Medicare an extrapolated amount. Providers generally decline to do so and resolve potential overpayment matters with their respective MAC. OIG continues to recommend refunds at the extrapolated amount largely for consistency. But OIG consistency only goes so far since OIG does not always audit providers using a randomly selected statistical sample and for those audit reports when other sampling techniques are used, OIG does not extrapolate its audit findings. See e.g., two recent audit reports for Tulare Regional Medical Center (A-09-13-02052) (posted 09/04/14); Tyler Prosthetics, Inc. A-06-13-0049 (posted 08/19/14). OIG decides when to use statistical sampling and extrapolation and when it does not – it is largely determined by the audit staff planning the audit protocol for that particular audit or series of audits.

Notwithstanding inconsistencies in its audit approach of providers, with regard to this hospice report it is notable that OIG clings to its tenuous position that, even with its concession that CMS will determine the overpayment amount, the hospice was overpaid “at least $447,467.” This suggests OIG is driven to show Congress that it will continue to “come down hard” on hospices, even those with very low error rates.

So why does OIG insist on using a statistical sampling plan and extrapolate its findings here, notwithstanding a very low error rate? The jaundiced view is OIG wanted to issue an audit report that garnered more attention and “Medicare recoveries” than a report with a small overpayment finding, especially given that this is its first hospice audit report in years. In its Operation Restore Trust Audits in 1996 and 1997, OIG reviewed multiple hospices but did not seek to extrapolate any of its sampled audit findings. But that was then and this is now. In recent years, OIG has expressed serious program integrity concerns in the hospice sector. Issuance of hospice audit reports with extrapolated findings will further OIG’s interest in the so-called “sentinel effect” – a critical audit report of one hospice may put others on notice that they could be next.

Hospices that find themselves the subject of such OIG audits should use extra vigilance in defending their positions. While challenging the use of extrapolation in the final audit report may feel like tilting at windmills, it is nonetheless important to do so. Additionally, ensure auditors are furnished all relevant documentation, including from other providers that may have a bearing on the level of care furnished and clinical eligibility. A finding of low error rates in hospice may well cause OIG to shift its limited audit resources elsewhere. One last observation – both OIG and Community Hospice agree that it is a good idea to improve procedures to ensure appropriate documentation from other providers (e.g., hospitals, physicians, nursing homes, etc.) is included in the patients’ medical records. That may be the most important lesson for hospice providers from this OIG audit.

Download a PDF of this blog to share with others in your organization.

]]>In Hospice, Every Day is Election DayKathy BrandtThu, 30 Oct 2014 13:20:18 +0000http://weatherbeenetwork.net/blog/2014/10/27/election-day50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:544e7cd1e4b0ddfd0e621d3bWhat does hospice have in common with political campaigns besides
elections? Unfortunately, more than you'd think. It's not to late to
reverse course and return to the days when journalists, patients/families,
and referring physicians were promoting the benefits of hospice. Our
colleague Kathy Brandt explores these similarities and ways each hospice
can work to repair the reputation of hospice.

I'm a political junkie; I love hearing news about the "too-close-to-call" races, listening to the latest poll data, and watching election night returns. For those of you who aren't as enamored as I am, the good news is that the 2014 mid-term elections will soon be over.

For hospices, elections happen every day. Unlike voters, hospices can't be apathetic when it comes to understanding the key issues related to the election and admission process. Since I'm not a regulatory expert, I'll leave it to my friends at Weatherbee Resources to write about compliance-related issues (including this recent blog regarding the changes to the Notice of Election process).

Instead this post serves as a reminder, in the context of the recent Washington Post series The Business of Dying, that hospice should have absolutely nothing in common with political campaigns. And yet, there are similarities:

It's not too late to reverse course and return to the days when journalists, patients/families and referring physicians were universally singing praises of hospice. What can you do to help improve the reputation of hospice in the US?

Promote resources that help patients/families understand how to select a quality hospice that is best for them;

Stop talking about your competitors - at all. Focus on being the best hospice in your community and promote your value, not your competitors' faults;

Be proactive, conduct regular audits of your systems and processes to ensure that your hospice is always in compliance with the regulatory requirements.

The 2016 election season will start as soon as the mid-term elections are over, let's hope that by the time election day 2016 is upon us, there will be little if anything in common between political campaigns and hospice.

]]>Back to the “Definition Board:” Defining Terminal IllnessSuzanne Karefa-Johnson, MDMon, 20 Oct 2014 17:00:00 +0000http://weatherbeenetwork.net/blog/terminal50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:54402740e4b03c0c4bccbe4cThe Medicare Hospice Benefit has always defined the terminal illness, not
as a single diagnosis, but as the interplay of conditions that together
cause an individual to have a prognosis of 6 months or less. At this
point, the proposed definition is open for comments. However, my guess is
that in the final determination there may well be a clear differentiation
between the definition of ‘terminal illness’ and that of the
‘principle/hospice-qualifying diagnosis’ to better underscore the
prognostic implication and comprehensive nature of the former.

In previous posts, we have stressed the importance of telling the ‘story’ of the patient – specifically in the hospice physician certification narrative, and in the determination of relatedness to the patient’s terminal illness. We have visited the regulatory and sub-regulatory guidance that frame how Part D and the Medicare Hospice Benefit interrelate.

I now propose we head back to the hook on which all this hinges – the definition of “terminal illness.” [Note: Please see the comment below from Judi Lund Person from NHPCO for further clarification of the current status of CMS's efforts to define/redefine "terminal illness']. Why? Because this is one of the top priorities of CMS for 2015. of The ensuing definition of “Related Conditions” is equally important. However, that will have to wait until the next post. This is not just a matter of semantics. In the FY2015 Hospice Wage Index Final Rule (79 FR 50451), released on August 22, 2014, and in the section soliciting comments on proposed definitions of these two terms, CMS carefully (and fairly long-windedly), lays out the philosophical, historical, and legal history of the Medicare Hospice Benefit, as we now know it.

To summarize the salient points, or the “Cliff Notes” version if you will...

The Medicare Hospice Benefit (MHB) was developed to focus on the “total person” at end of life

Hospices were to “maintain(ing) continuous clinical control over all aspects of care”

The MHB is “risk-based,” a “fixed sum for all-inclusive end of life care”

Analyses of payments for Parts A, B, and D services have raised concerns that there is an “unbundling” of hospice services with “cost shifting” to Medicare B and D for services that should be paid for out of the per-diem, capitated hospice payment system for patients at end-of-life

See the theme that is emerging? CMS’s argument is that as a vehicle of care delivery, hospice is an integrated model and does not lend itself to compartmentalization; that it is an economic and clinical model that assumes responsibility for the care of the whole person. They reiterate that the 6 months or less prognosis is the key determinant in the definition of “terminally ill” and that “the individual’s whole condition plays a role in that prognosis.” Again, in CMS’s words:

“All body systems are interrelated”

In determining prognosis, “assessment should include the ‘total person,’ ‘acute and chronic conditions’ and ‘controlled and uncontrolled conditions’”

Conditions that are a part of the bundled, covered hospice services should include pre-existing conditions and controlled pain and symptoms

In conclusion, CMS includes the following definition of terminal illness for which they are seeking comments from the stakeholder community, for use in “possible future rulemaking” (take a deep breath):

"Abnormal and advancing physical, emotional, social and/or intellectual processes which diminish and/or impair the individual’s condition such that there is an unfavorable prognosis and no reasonable expectation of a cure; not limited to any one diagnosis or multiple diagnoses, but rather it can be the collective state of diseases and/or injuries affecting multiple facets of the whole person, are causing progressive impairment of body systems, and there is a prognosis of a life expectancy of 6 months or less.”

Do you think there’s anything they left out? Exactly! Terminal illness, by this definition, is a high level, sweeping, and inclusive view of the failing body systems which, when considered in toto, contribute to the limited prognosis. It is a prognostic rather than diagnostic term.

SO… what does this mean for hospices?

THE “DO’s:”

Physicians need to think about all the conditions that are contributing to the 6 months or less prognosis when certifying the patient as terminally ill

The principal diagnosis should be chosen as the diagnosis most contributory to the limited prognosis

The physician’s certification narrative must document the choice of principal diagnosis and all conditions considered in determining the terminal prognosis (this not only establishes the patient as terminally ill and therefore clinically eligible for the hospice benefit, it also drives the relatedness decisions, which we’ll cover in the next blog)

In some cases, the principal diagnosis will be clear (e.g., Stage IV pancreatic cancer). In others, it may not be (e.g., debilitated patient with a rapid trajectory of decline with a history of multiple chronic conditions). The physician needs to choose the diagnosis s/he will most likely list as the primary cause of death on the death certificate

Hospice physicians are not limited to specific diagnoses that are covered by a published Local Coverage Determination (LCD) guideline; the principal diagnosis might well be without an appropriate LCD (e.g., peripheral arterial disease)

All medically necessary services for all component conditions of the terminal prognosis are the hospice’s responsibility along the continuum of care

The principal diagnosis and other prognosis-impacting conditions need to be re-evaluated as dictated by the patient’s clinical course and included in the physician’s documentation, interdisciplinary assessments, and plan of care

THE “DON’T’s:”

As of 10/1/14, debility and adult failure to thrive can no longer be designated as principal hospice diagnoses. They can, however, be listed as comorbidities/secondary diagnoses that are contributory to the terminal prognosis

Dementia (290-295) cannot be used as the principal hospice diagnosis. It is the manifestation of an underlying condition (e.g., cerebral atherosclerosis), which should be named as the principal hospice diagnosis with dementia as a secondary condition

In summary, CMS is making the point that the Medicare Hospice Benefit has always defined the terminal illness, not as a single diagnosis, but as the interplay of conditions that together cause an individual to have a prognosis of 6 months or less. At this point, the proposed definition is open for comments. However, my guess is that in the final determination, although the two have at times been used interchangeably by the hospice community, there may well be a clear differentiation between the definition of ‘terminal illness’ and that of the ‘principle/hospice-qualifying diagnosis’ to better underscore the prognostic implication and comprehensive nature of the former. In the meantime, CMS will be paying attention to how terminal illness is being defined and addressed in the care of hospice patients. Ongoing documentation in the clinical record should very clearly reflect the hospice physician’s and team’s recognition of the complex and multifarious nature of terminal illness, and the assumption of full responsibility for its palliation along the continuum of care, thereby continuing to “(make) good on their promise to do a better job than conventional Medicare services for those who (are) at end-of-life.”

Resources:

]]>Keep Calm and Prepare for IMPACT - Part 2Joy BarryTue, 14 Oct 2014 15:23:47 +0000http://weatherbeenetwork.net/blog/2014/10/11/impact250f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:54397967e4b03db85e42750cProactively preparing for medical review positions your hospice for the
best possible outcome in the event you receive IMPACT-related scrutiny,
Additional Development Requests (ADRs) or become the target of any audits
or investigations related to patient eligibility.

As expected, President Obama signed the Improving Medicare Post Acute Care Transformation (IMPACT) Act on October 6th, 2014. So it is now official: 1) for the next ten years hospices will be surveyed no less frequently than every three years for compliance with the Medicare Conditions of Participation; and 2) there will be additional scrutiny of hospices that exceed the yet to be determined threshold of patients on service longer than 180 days.

At Weatherbee, we still question how much impact this much heralded legislation will have on improving the quality of care provided by hospices (see our blog article on this topic here). However, our focus and commitment is to help hospices prepare for the inevitable increased scrutiny. Part 1 of this blog post presented ideas for preparing for surveys related to compliance with the Medicare Conditions of Participation. These surveys are likely to begin six months after the enactment of the legislation.

The focus of this blog post is preparation for the medical reviews of hospices that exceed the yet to be determined threshold of long length of stay patients. There is likely to be future rule making that determines which Medicare contractor will conduct these reviews as well as clarification regarding the percentage of long lengths of stay that will trigger the reviews. It is expected that CMS will follow the recommendation in MedPAC's 2009 report that hospices with 40% or more of their patients with stays exceeding 180 days be subject to review. Although these details still need to be determined, it is clear that the additional scrutiny will focus on the hospice needing to demonstrate the patient's initial and continued eligibility for hospice care.

Whether your hospice has a high percentage of long-stay patients or not, proactively preparing for medical review positions your organization for the best possible outcome in the event you receive Additional Development Requests (ADRs) or become the target of any audits or investigations related to patient eligibility. The following considerations and activities should be standard components of the auditing and monitoring functions of your hospice's corporate compliance program and should occur under the direction and supervision of your hospice's compliance officer.

Regularly monitor your hospice's census to determine percentage of patients: 1) on service for more than 180 days; 2) with non-cancer diagnoses; and 3) residing in facilities (SNFs or ALFs)

Create and implement audit tools and protocols specific to evaluating a patient's technical and clinical eligibility for hospice care as well as for higher levels of care. For example,

Develop an audit calendar, inclusive of volumes, frequencies, and compliance goals. For example: On a monthly basis, conduct an audit of X% of all newly admitted patient records to evaluate compliance with Notice of Election requirements. The compliance goal is 100%. [Note: Once the compliance goal is achieved and maintained for X consecutive months, the volume and/or frequency may be reduced.]

Determine the audit sample:

Decide how each audit sample will be established (e.g., random or targeted). For example, selecting a random sample of 10% of a 100-patient census would result in including every 10th patient on the list in the audit sample. Selecting a targeted sample of patients would require limiting the list to only a given type of patient (i.e., patients who received the general inpatient level of care during a particular month) and then selecting a random sample of those patients. [Note: Using RAT-STATS methodology for audit sampling is not recommended unless the audit is being conducted under attorney-client privilege for a very specific purpose.]

Once the audit type, frequency, and sample have been established, communicate with the billing department to ensure that all claims associated with pre-billing audits are held pending completion of the audit. [Note: Weatherbee recommends conducting only pre-billing clinical record audits, unless the audit is being conducted under attorney-client privilege for a very specific purpose.]

Ensure that all auditors: 1) receive training on how to use the audit tool(s); 2) follow the established protocol; and, 3) report all aberrant findings to the designated person in a timely manner.

Review the audit results and:

Assure full compliance with all payment-related requirements prior to allowing the billing department to submit the held claims to the hospice's Medicare Administrative Contractor (MAC) for payment;

Develop a Performance Improvement Plan to identify and address the root cause of all aberrant findings; and,

Determine whether the audit type, frequency, and/or sample needs to be adjusted going forward. As a general rule, the more high-risk, high volume, and problem-prone an issue is, the more frequently it should be audited to ensure full compliance.

Conducting pre-billing audits provides an opportunity to evaluate the type, frequency, and quality of interdisciplinary documentation to demonstrate the patient's initial and ongoing eligibility for hospice care. It allows the opportunity to identify and potentially correct payment-related deficiencies prior to submitting claims. This proactive approach results in cleaner claims and fewer payment denials. In addition, if your hospice is subject to the IMPACT Act's medical review due to exceeding the long length of stay threshold, this proactive auditing and monitoring of long length of stay patient eligibility will make responding to the additional scrutiny less onerous.

If you need help, Weatherbee Resources, Inc. offers clinical record auditing and other survey-readiness consultations. For more information, contact our consulting division at 866-969-7124 or visit our website.

]]>Keep Calm and Prepare for IMPACT - Part 2Keep Calm...and Prepare for IMPACT - Part 1Joy BarryThu, 25 Sep 2014 15:23:19 +0000http://weatherbeenetwork.net/blog/2014/9/25/prepare-for-impact50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:542405e8e4b0a5427e45ae9fThe passage of the 2014 IMPACT Act will bring more survey's to hospices. In
this first of two blog posts, Joy Barry details what hospices need to do
now to prepare for more frequent surveys of a hospice’s compliance with the
Medicare Conditions of Participation (CoPs).

Heather Wilson provided a discussion of H.R. 4994, the Improving Medicare Post Acute Care Transformation (IMPACT) Act of 2014 in her recent blog post Will the IMPACT Act Really Help the Hospice Industry? Although I agree with her contention that increased surveys and oversight are not a silver bullet or a panacea for the many challenges facing hospices, nevertheless, hospices need to prepare for the increased scrutiny.

This is the first of two blog posts I am writing on what hospices need to do now to prepare for more frequent surveys and the medical review audits of long length of stay patients. This first post focuses on preparation for more frequent surveys of a hospice’s compliance with the Medicare Conditions of Participation (CoPs).

Unless a hospice is accredited, it may not have experienced a survey from a State surveyor in many years, even, quite possibly, since before the “new” CoPs became effective at the end of 2008. With increased survey frequency on the immediate horizon for all hospices, it is time to ensure your hospice has not become complacent or lax with compliance with the CoPs.

The following are activities to consider:

The hospice’s Executive Director (or the appointed designee – e.g., Compliance Officer, QAPI Coordinator, etc.) should obtain and review, at a minimum, the following documents:

Ensuring that s/he knows the regulations and how to use the audit tool;

Setting an audit completion date;

Obtaining the completed audit tool from the department manager and reviewing the results together; and

Identifying areas of non-compliance and having the department manager establish a Performance Improvement Plan (PIP).

When developing a PIP, ensure that:

The root cause of the problem (i.e., the non-compliant issue or practice) is accurately identified;

All relevant people, paper, and/or processes are included in the corrective action (i.e., the staff know what is expected of them and what is required for compliance; the hospice’s forms, tools, policies, and other documents are valid and compliant; and, internal systems and staff practices support compliance); and,

Follow up auditing and monitoring occurs to ensure that the PIP was successful and full compliance was achieved and maintained over time.

When conducting mock surveys, it is important to include information from as many sources as possible and to validate the veracity of all information. For example, surveys often include the following:

Direct observation (e.g., interdisciplinary group meetings; the provision of patient care during home visits; a tour of the hospice’s inpatient unit; etc.); and

A review of internal systems and processes (e.g., the process for involving the patient’s attending physician in developing and updating the plan of care; whether the interdisciplinary team is meeting its minimum patient visit frequency each week; etc.).

Proactively conducting a mock survey provides an opportunity to evaluate your hospice’s level of regulatory compliance while allowing you to “see” the organization through fresh eyes. The overarching goal is to achieve a state of constant survey readiness. When the surveyor arrives, unannounced on your doorstep, everyone will know what to expect and what to do to demonstrate your hospice’s compliance with regulations.

Stay tuned for our next post that deals with the Impact Act’s second type of survey – medical reviews of long length of stay patients.

]]>Will the Impact Act really help the hospice industry?Heather Wilson, PhDSun, 21 Sep 2014 02:40:51 +0000http://weatherbeenetwork.net/blog/2014/9/15/hospiceact50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:5416d24ee4b05407cce64599Am I a party pooper? A Debbie Downer? You can decide, but I don't think
the hospice provisions in the Impact Act of 2014 are going to do much to
increase transparency, sort out the "good" hospices from the "bad," or,
sadly, improve the quality of care provided by hospices. Let me explain...

Not.

Am I a party pooper? A Debbie Downer? You can decide, but I don't think the hospice provisions in the Impact Act of 2014 are going to do much to increase transparency, sort out the "good" hospices from the "bad," or, sadly, improve the quality of care provided by hospices. Let me explain...

For the next ten years, hospices will be surveyed no less frequently than every three years;

There will be medical reviews of hospices that have a yet-to-be determined percentage of patients with a length of stay longer than 180 days.

These provisions, interestingly, represent the two types of hospice scrutiny:

Medicare certification and complaint surveys for compliance with the Medicare Conditions of Participation (CoPs) in Subparts C and D of the hospice regulations. The focus of these surveys is on patient health and safety and quality of care; and

Payment-related scrutiny dealing primarily with Subpart B of the hospice regulations. The focus of these audits is initial and continued eligibility for hospice care and higher levels of care, related/not related issues, potential fraud and abuse, etc.

Let's consider each of these types of scrutiny separately and look at how the IMPACT Act will and will not affect them.

Survey & Certification Scrutiny (CoPs Compliance)

This first type of scrutiny has been sorely lacking in the hospice industry due to budgetary cuts as well as a lack of a statutory mandate for hospice survey frequency (as has existed for home health agencies and skilled nursing facilities). This has resulted in hospices being the lowest priority for survey and certification surveys for many years. Hospices can go more than 10 years without ever being surveyed. The Office of Inspector General (OIG) expressed its concern about this in a 2007 report regarding the inadequacies of CMS oversight of hospices. NHPCO and NAHC have both advocated for years for more frequent surveys.

But let's step back. It has not been that terrible. Complaint surveys have continued so there has been a mechanism in place to deal with quality of care when issues surface to the level of complaints. Though clearly less than ideal, surveys have occurred. In addition, CMS has required that those 5% of providers at most risk for performing badly be surveyed each year. Again, not ideal, but another mechanism in place to try to deal with the need for oversight within significant budgetary constraints. And there have been enough surveys to generate CMS' annual list of top ten survey deficiencies, which is virtually the same every year.

But here is the heart of my argument. There are three national accrediting organizations that have deeming authority for hospices: the Joint Commission, CHAP, and ACHC. To be awarded deeming authority, each of these organizations has gone through an arduous and ongoing process to demonstrate to CMS that their standards meet and/or exceed the Medicare Conditions of Participation for hospices. It is believed that hospices that undergo voluntary accreditation are demonstrating their commitment to quality care and high standards. Hospices that are accredited by these organizations may be deemed in compliance with Medicare regulations and must be surveyed every 3 years in order to maintain their accreditation. It is difficult to find exact numbers but some estimate as many as 1 in 4 hospice locations are accredited by one of the three accrediting organizations. Or, to perhaps illustrate my point more poignantly, many of the hospices mentioned by Peter Whoriskey in his Washington Post articles skewering hospices are accredited. For example, in his excruciating article entitled Terminal Neglect? How some hospices treat dying patientshe cites the following hospices:

LifePath Hospice - accused of not providing continuous care when it was warranted. LifePath is accredited by the Joint Commission.

Access Hospice Care - accused of not providing documented nursing visits for patients in pain/near death and failing to provide any continuous care in 2011 or 2012. Access Hospice Care is accredited by the Joint Commission.

Mar Vista Hospice - accused of failing to provide a visit or pain management when a patient needed it. Mar Vista Hospice is accredited by the Joint Commission.

Heartland Hospice/HCR ManorCare - a branch in Santa Rosa did not provide any GIP or continuous care. Heartland/HCR ManorCare (all branches) is accredited by CHAP.

Clarity Hospice - accused of not providing any continuous care or GIP during 2012. Clarity Hospice is accredited by CHAP.

In other articles, Whoriskey criticizes Aseracare Hospice (accredited by CHAP) and VITAS (accredited by the Joint Commission). In addition, Optum, formerly known as Evercare has been in the hospice fraud news lately and Optum is accredited by CHAP.

So what are we to make of this? By virtue of their accreditation, all of the hospices mentioned above that have been in the "hospice bad news" recently have, in fact, been surveyed every three years. If none of them were accredited I might be more inclined to believe that the problems cited were due to infrequent surveys or could be solved by increased oversight. The fact that most of these hospices ARE accredited confirms my contention that the IMPACT Act's provision to increase the frequency of hospice surveys to at least every three years is not likely to make that much of a difference. An increase in the frequency of surveys for all hospices, accredited or not, is most likely a good thing. However, it is not the solution to the many problems and issues raised in the Washington Post articles.

Let's move on to payment-related scrutiny.

Payment-related Scrutiny

The second hospice provision of the Impact Act, requiring medical review of hospices with a soon-to-be-determined percentage of long length of stay patients, strikes me as more or less what hospices are already dealing with - in spades. For at least the past 5 years, hospices have faced an unprecedented level of payment scrutiny from the alphabet soup of Medicare contractors - particularly MACs and ZPICs.

Payment-related scrutiny has to do with Subpart B of the hospice regulations (as opposed to the CoPs in Subparts C & D) with the focus on eligibility, election, levels of care, discharge etc. The primary focus of payment scrutiny and the primary risk area for hospices is patient eligibility for admission to hospice care, eligibility for recertification and eligibility for higher levels of care. Medicare contractor auditing is a pay and chase system that is extremely arduous, expensive and tedious for everyone involved. It is hard to imagine that adding yet another type of Medicare contractor audit is going to make any difference other than increase the burdens of hospices already trying to survive the intense financial and operational havoc caused by current levels of hospice payment scrutiny. It remains to be seen who the audits will be assigned to - which Medicare contractor (oh, so many choices!).

There is nothing really new about this "new" medical review in the IMPACT Act. It will still be about the quality of documentation regarding patient eligibility. Yes, it may be more targeted with a focus on hospices that meet or exceed the determined threshold of patients with long lengths of stay. Perhaps hospices will have a greater incentive to keep their numbers of long length of stay patients below that threshold. Will that contribute to improved quality of care? Not likely.

Conclusion

So there you have it. Is the Impact Act a good thing? Sure. It certainly can't hurt. But it is not a silver bullet, a panacea. To think that these provisions are just what hospices need to turn the recent tide of negative public opinion and attention around and solve the quality of care problems our industry faces is naive and simplistic. My wish, which hopefully is not naive and simplistic too, is that we will see the IMPACT Act as only one tiny baby step in the direction of engaging in a thoughtful, non-defensive, conversation about what is happening to hospice care in the United States and what we need to do to rebuild public trust in the quality of care provided by hospices.

Posted by Heather P. Wilson, PhD CEO, Weatherbee Resources, Inc.

Are you worried about the increased frequency of surveys and length of stay audits? Prepare now. Weatherbee can help. See information additional information here or send us an email today to consulting@weatherbeeresources.com.

]]>The New IOM Report on Dying in AmericaIOMKathy BrandtThu, 18 Sep 2014 12:07:55 +0000http://weatherbeenetwork.net/blog/2014/9/18/iom-report50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:541abdb3e4b0a990b339e7baThe publication of the Institute of Medicine's 2014 report on Dying in
America offers a significant opportunity to elevate the challenges of
caring for people with advanced serious illness. Since hospice is the only
Medicare benefit designed specifically for "the dying" and so many
Americans are accessing hospice hours or days before they die, the issue of
timely access to hospice care must be addressed.It's been 17 years since the Institute of Medicine (IOM) released their original end-of-life focused report, Approaching Death: Improving Care at the End of Life. Today (September 17, 2014), during a live-streamed event, the IOM released Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life.

The 1997 Report

The 455-page Approaching Death report, which documented the state of end-of-life care, provides context for the 2014 report. I've posted my very brief summary of the "problems" and "solutions" identified in the report for those who are interested. Many of those recommendations served as catalysts for improvement in the care of the dying and seriously ill. Philanthropic organizations invested millions in developing palliative care, engaging communities at the national, state and local levels, and establishing evidence-based clinical and organizational practices.

The 2014 Report

Given the impact of the last IOM report, organizations will benefit from reading the full IOM report, or at least the Key Findings and Recommendations. I certainly haven't read the full report as yet, however here's my summary of the findings and recommendations, followed by a few initial thoughts on the implications for hospices and those advocating to improve end-of-life care.

Recommendation 1: Delivery of Care - payers "should cover the provision of comprehensive care for individuals with advanced serious illness who are nearing the end of life." The IOM report states that comprehensive care should include all the essential elements of quality hospice care - patient-centered, holistic, coordinated, and value-based. This recommendation also states that all health care organizations should work to ensure that "all people with advanced serious illness should have access to skilled palliative care or, when appropriate, hospice care in all settings..." That phrase - or when appropriate, hospice care - is the only specific recommendation to referral to hospice in the summary document. More on that in a bit. Recommendation 1 also calls for transparency and accountability through public reporting of quality and costs of care and that people's individual choices should be honored, including the right to decline care or services.

Recommendation 2: Clinician–Patient Communication and Advance Care Planning - organizations should develop quality standards for advance care planning and communication, which are "measurable, actionable, and evidence based." These standards should evolve over time and be adopted by payers and health care organizations, integrating them into "assessments, care plans, and the reporting of health care quality" assessments, care plans, and the reporting of health care quality. Furthermore, payers should tie the standards to reimbursement and professional organizations to credentialing and licensing. The goal of this recommendation is to encourage everyone - including children - to participate in their care decision making and receive care consistent with their stated preferences. Additionally, the IOM is seeking to motivate clinicians to become actively engaged in all aspects of ongoing advance care planning throughout a person's life.

Recommendation 3: Professional Education and Development - everyone, from providers to accrediting organizations to regulators and credentialing bodies - should establish training/licensure requirements that strengthen clinician palliative care expertise and skills. There are seven specific items related to this recommendation, including a suggestion that all physicians "responsible for managing advanced serious illness (including primary care..." be required to receive palliative care education and clinical experience. As an aside, I don't see (at first glance) anything that encourages health care providers to regularly offer, subsidize, or promote palliative care continuing education for staff.

Recommendation 4: Policies and Payment Systems - payers and health care providers should integrate the financing of services, including incentives to achieve coordination of care and improve shared decision making. This recommendation emphasizes the need for universal electronic health records that are accessible across care settings and providers and incorporate essential elements of advance care planning. Additionally, states are encouraged to implement the Physician Orders for Life-Sustaining Treatment (POLST) paradigm.

Recommendation 5: Public Education and Engagement - national, state and community organizations should provide informative resources and facilitate ongoing engagement regarding the care of those living with a serious illness. Specific education and engagement foci are detailed including outreach to underserved populations, values-based dialogues and efforts to "dispel misinformation that may impede informed decision making and public support for health system and policy reform regarding care near the end of life." Health care organizations are encouraged to provide information about end-of-life care and the report asks payers to disseminate potentially proprietary research that can improve the efficacy of audience-specific messaging.

kb's Take

It's been a long day, listening to the webcast, reading the summary document, and writing this blog and I'm sure I'll have more thoughts on this after I spend more time reviewing it, but for now, here are some thoughts regarding the potential implications for national, state, and community-based advocates for, and providers of, hospice:

In a very politically-sensitive, inclusive, and not at all defensive way, I think we need to engage our colleagues in a discussion regarding the lack of hospice-specific recommendations. I understand that the process was entirely consensus based, was focused more on the individuals and less on the providers, and that many of the committee members represented the broader field of palliative care, yet in a report called "Dying in America" one could expect to see a little more emphasis on hospice. Since hospice is the only Medicare benefit designed specifically for "the dying" and so many Americans are accessing hospice hours or days before they die, the issue of timely access to hospice care must be addressed.

Another distressing omission was the lack of specific recommendations related to improving access to quality end-of-life care within communities of color. During the webcast today the IOM announced that it is developing a year-long dissemination plan that includes an emphasis on public engagement and education. As I tweeted earlier today, I hope that this dissemination plan engages many diverse stakeholders representing different perspectives, including a meaningful representation of communities traditionally-underserved by hospices and other palliative care providers.

The majority of the recommendations describe and/or promote the goals of US hospice founders when they championed end-of-life care and started the hospice movement. Back in 1989 when I started in this field hospices were the only practitioners consistently providing quality relief from the burdens of serious illness and related "curative" treatments. That is no longer true. And that isn't a bad thing: access to palliative care, in advance of hospice Medicare benefit services, is, was and, will continue to be needed in all care settings.

This year several high-profile national stories have garnered significant attention to some highly questionable practices. While I disagree with the conclusions and sensationalized approach of the journalists, the comments of members of the public demonstrates a need for vigilance. All hospices and those who work with, and on behalf of hospice providers must do everything possible to ensure the provision of the highest quality care and utilization of ethical business practices. I firmly believe the majority of hospice professionals want to do the right thing and we must all work to help them do it.

]]>What You Need to Know About the October 1st Notice of Election Changes Carrie CooleyFri, 12 Sep 2014 20:33:50 +0000http://weatherbeenetwork.net/blog/2014/9/11/noe-notr50f0bb6ae4b08d03393958a6:50f0bb6be4b08d03393958ad:5411c901e4b0e0970bd2b10aBy now you have hopefully heard about the changes regarding the hospice
Notice of Election (NOE), Notice of Termination/Revocation (NOTR), and
processes for identifying/changing the attending physician that take effect
October 1, 2014. This blog post details these changes and identifies best
practices to comply with the changes. At the conclusion of this post is a
downloadable PDF that you can share with everyone who needs this
information.

By now you have hopefully heard about the changes regarding the hospice Notice of Election (NOE), Notice of Termination/Revocation (NOTR), and processes for identifying/changing the attending physician that take effect October 1, 2014. This blog post details these changes and identifies best practices to comply with the changes. At the conclusion of this post is a downloadable PDF that you can share with everyone who needs this information.

The Background

The Medicare Hospice Benefit (MHB) requires that each beneficiary or patient intentionally choose hospice care. This patient choice is documented in the NOE. The hospice cannot provide any services or bill for days of care before the effective date the NOE is signed.

Beginning October 1, 2014, The NOE must include:

Identification of the hospice

Acknowledgement of the palliative versus curative care

Medicare waiver for services related to the terminal illness and related conditions

Date of election

Signature of beneficiary / representative

Name of the patient’s attending physician

Acknowledgment that the identified attending physician was the patient’s / representative’s choice

The MHB also requires that a hospice use a NOTR, also known by its type of bill (8XB), to communicate to the Medicare Administrative Contractor (MAC) that a beneficiary has been discharged alive or revoked the Medicare Hospice Benefit within 5 calendar days, unless a final bill has been submitted. The NOTR contains the same data elements as the NOE and is entered via Direct Data Entry (DDE).

Filing the NOE

Beginning October 1, 2014 the NOE must be submitted to the Medicare Administrative Contractor (MAC) within 5 calendar days.

When a patient elects hospice, either as a new admission or a transfer from another hospice, the hospice must complete multiple form locators (FL) of the Uniform Bill (Form CMS-1450), which is the election notice.

This election, Form CMS-1450) is sent to the MAC by mail, messenger, or DDE.

If a patient is admitted to hospice before the month that he/she is eligible for Medicare (e.g., before age 65), then an NOE is not submitted. If the patient is still receiving hospice services on the first day of the month he/she turns 65, then the NOE must be signed and submitted within five days of the first of that month.

If a NOE is not submitted and received by the MAC within 5 calendar days, the hospice is financially liable for all care from the date of election until the date the NOE is filed. If the NOE is late, the hospice cannot bill for any days of care provided prior to the date the NOE is filed.

CMS has provided for the following exceptions to the timely filing requirements:

Fires, floods, earthquakes, or other unusual events that inflict extensive damage to the hospice’s ability to operate

CMS or MAC system filing issues beyond the control of the hospice

A newly Medicare-certified hospice that is either:

Notified of that certification after the Medicare certification date or

Awaiting its user ID from its MAC

Other circumstances determined by CMS to be beyond the control of the hospice

In order to be approved for an exception, the hospice must document the circumstances to support the request for an untimely NOE exception and submit that to the MAC. The MAC will determine if the exceptional circumstance qualifies for an untimely NOE filing exception.

CMS also stated that the following will NOT be allowed as exceptions for timely filing of the NOE:

Personnel issues

Internal IT issues

Not knowing the requirements

Failure of the hospice to have back-up staff to file the NOE

Filing the NOTR

Beginning October 1, 2014 the hospice must submit a NOTR within 5 calendar days of the discharge or revocation, unless a final hospice claim has been filed

There is no need to file a NOTR when a patient dies

Unlike the NOE, there is currently no penalty or consequence if a hospice files the NOTR late

Best Practices for Filing the NOE/NOTR

File the NOE/NOTR as soon as possible after the election, just in case there is a problem with the submission. Don’t wait until the 5th day

Evaluate your hospice’s internal process for NOE completion and notifying the MAC of a beneficiary’s election to ensure the timely submission of the NOE

Patient Designation of Attending Physician

The Social Security Act (at 1861(dd)(3)(B)) defines the hospice attending physician as, “The physician or nurse practitioner, who may be employed by a hospice program, whom the individual identifies as having the most significant role in the determination and delivery of medical care to the individual at the time the individual makes an election to receive hospice care.” Under Patient’s Rights (§ 418.52(c)(4)), The Hospice Conditions of Participation states that the hospice patient has the right to choose his/her attending physician.

Effective October 1, 2014 the Notice of Election must include the name of the attending physician the patient / representative has chosen

The NOE must also include a mechanism for the patient / representative to acknowledge that the identified attending physician listed on the NOE was his / her choice

Each hospice must develop a Change in Attending Form, which must be signed by the patient / representative

The Change in Attending form must include:

Physician’s full name

Office address

NPI number

Date change is to be effective (effective date can be no earlier than the date the form is signed)

Date statement is signed

Patient / representative’s signature

Acknowledgement that the change is the patient’s / representative’s choice

If the physician is unable or unwilling to serve as the patient’s attending physician, that must be documented in the patient’s clinical record and the patient / representative must be informed that they may choose another attending physician; including a physician or nurse practitioner from the hospice or the community

Compliance Risks Associated with the Designation of the Attending Physician

The following practices could lead to survey deficiencies and/or a non-compliance audit:

Automatically changing the patient’ attending physician when a patient moves to an inpatient setting for the General Inpatient (GIP) level of care

“Assigning” an attending physician based on physician availability, rather than documented patient/representative choice

Failure to obtain the attending physician’s signature on the initial certification

Best Practices Regarding the Patient Designation of the Attending Physician

Modify the NOE to include the name of the attending physician and language that affirms the choice of the attending physician was made by the patient / representative.

Develop a process regarding how to explain the challenges involved when a hospitalist is selected to be the attending by the patient / representative

Determine where in the clinical record changes regarding the attending physician will be documented, including information about the new attending physician